hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|GA,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Dodge County Hospital,2024-07-01,2.0.0,Dodge County Hospital,"901 Griffin Ave Eastman, GA 31023",045-041,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|AETNA|COMMERCIAL|negotiated_dollar,standard_charge|AETNA|COMMERCIAL|negotiated_percentage,standard_charge|AETNA|COMMERCIAL|negotiated_algorithm,estimated_amount|AETNA|COMMERCIAL,standard_charge|AETNA|COMMERCIAL|methodology,additional_payer_notes|AETNA|COMMERCIAL,standard_charge|AETNA|MEDICAL_RENTAL_FIRST_HEALTH|negotiated_dollar,standard_charge|AETNA|MEDICAL_RENTAL_FIRST_HEALTH|negotiated_percentage,standard_charge|AETNA|MEDICAL_RENTAL_FIRST_HEALTH|negotiated_algorithm,estimated_amount|AETNA|MEDICAL_RENTAL_FIRST_HEALTH,standard_charge|AETNA|MEDICAL_RENTAL_FIRST_HEALTH|methodology,additional_payer_notes|AETNA|MEDICAL_RENTAL_FIRST_HEALTH,standard_charge|AETNA|MEDICARE|negotiated_dollar,standard_charge|AETNA|MEDICARE|negotiated_percentage,standard_charge|AETNA|MEDICARE|negotiated_algorithm,estimated_amount|AETNA|MEDICARE,standard_charge|AETNA|MEDICARE|methodology,additional_payer_notes|AETNA|MEDICARE,standard_charge|AMBETTER_OF_PEACHSTATE|COMMERCIAL|negotiated_dollar,standard_charge|AMBETTER_OF_PEACHSTATE|COMMERCIAL|negotiated_percentage,standard_charge|AMBETTER_OF_PEACHSTATE|COMMERCIAL|negotiated_algorithm,estimated_amount|AMBETTER_OF_PEACHSTATE|COMMERCIAL,standard_charge|AMBETTER_OF_PEACHSTATE|COMMERCIAL|methodology,additional_payer_notes|AMBETTER_OF_PEACHSTATE|COMMERCIAL,standard_charge|AMERIGROUP|MEDICAID|negotiated_dollar,standard_charge|AMERIGROUP|MEDICAID|negotiated_percentage,standard_charge|AMERIGROUP|MEDICAID|negotiated_algorithm,estimated_amount|AMERIGROUP|MEDICAID,standard_charge|AMERIGROUP|MEDICAID|methodology,additional_payer_notes|AMERIGROUP|MEDICAID,standard_charge|AMERIGROUP|PEACHCARE|negotiated_dollar,standard_charge|AMERIGROUP|PEACHCARE|negotiated_percentage,standard_charge|AMERIGROUP|PEACHCARE|negotiated_algorithm,estimated_amount|AMERIGROUP|PEACHCARE,standard_charge|AMERIGROUP|PEACHCARE|methodology,additional_payer_notes|AMERIGROUP|PEACHCARE,standard_charge|ANTHEM_BCBS|COMMERCIAL|negotiated_dollar,standard_charge|ANTHEM_BCBS|COMMERCIAL|negotiated_percentage,standard_charge|ANTHEM_BCBS|COMMERCIAL|negotiated_algorithm,estimated_amount|ANTHEM_BCBS|COMMERCIAL,standard_charge|ANTHEM_BCBS|COMMERCIAL|methodology,additional_payer_notes|ANTHEM_BCBS|COMMERCIAL,standard_charge|CARESOURCE|MEDICAID|negotiated_dollar,standard_charge|CARESOURCE|MEDICAID|negotiated_percentage,standard_charge|CARESOURCE|MEDICAID|negotiated_algorithm,estimated_amount|CARESOURCE|MEDICAID,standard_charge|CARESOURCE|MEDICAID|methodology,additional_payer_notes|CARESOURCE|MEDICAID,standard_charge|CARESOURCE|MEDICARE|negotiated_dollar,standard_charge|CARESOURCE|MEDICARE|negotiated_percentage,standard_charge|CARESOURCE|MEDICARE|negotiated_algorithm,estimated_amount|CARESOURCE|MEDICARE,standard_charge|CARESOURCE|MEDICARE|methodology,additional_payer_notes|CARESOURCE|MEDICARE,standard_charge|CIGNA|COMMERCIAL|negotiated_dollar,standard_charge|CIGNA|COMMERCIAL|negotiated_percentage,standard_charge|CIGNA|COMMERCIAL|negotiated_algorithm,estimated_amount|CIGNA|COMMERCIAL,standard_charge|CIGNA|COMMERCIAL|methodology,additional_payer_notes|CIGNA|COMMERCIAL,standard_charge|HUMANA|EPO|negotiated_dollar,standard_charge|HUMANA|EPO|negotiated_percentage,standard_charge|HUMANA|EPO|negotiated_algorithm,estimated_amount|HUMANA|EPO,standard_charge|HUMANA|EPO|methodology,additional_payer_notes|HUMANA|EPO,standard_charge|HUMANA|HMO|negotiated_dollar,standard_charge|HUMANA|HMO|negotiated_percentage,standard_charge|HUMANA|HMO|negotiated_algorithm,estimated_amount|HUMANA|HMO,standard_charge|HUMANA|HMO|methodology,additional_payer_notes|HUMANA|HMO,standard_charge|HUMANA|POS|negotiated_dollar,standard_charge|HUMANA|POS|negotiated_percentage,standard_charge|HUMANA|POS|negotiated_algorithm,estimated_amount|HUMANA|POS,standard_charge|HUMANA|POS|methodology,additional_payer_notes|HUMANA|POS,standard_charge|HUMANA|PPO|negotiated_dollar,standard_charge|HUMANA|PPO|negotiated_percentage,standard_charge|HUMANA|PPO|negotiated_algorithm,estimated_amount|HUMANA|PPO,standard_charge|HUMANA|PPO|methodology,additional_payer_notes|HUMANA|PPO,standard_charge|HUMANA|MEDICARE_PPO|negotiated_dollar,standard_charge|HUMANA|MEDICARE_PPO|negotiated_percentage,standard_charge|HUMANA|MEDICARE_PPO|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE_PPO,standard_charge|HUMANA|MEDICARE_PPO|methodology,additional_payer_notes|HUMANA|MEDICARE_PPO,standard_charge|MEDICARE|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|MEDICARE,standard_charge|MEDICARE|MEDICARE|methodology,additional_payer_notes|MEDICARE|MEDICARE,standard_charge|PSHP|MEDICAID|negotiated_dollar,standard_charge|PSHP|MEDICAID|negotiated_percentage,standard_charge|PSHP|MEDICAID|negotiated_algorithm,estimated_amount|PSHP|MEDICAID,standard_charge|PSHP|MEDICAID|methodology,additional_payer_notes|PSHP|MEDICAID,standard_charge|UHC|COMMERCIAL|negotiated_dollar,standard_charge|UHC|COMMERCIAL|negotiated_percentage,standard_charge|UHC|COMMERCIAL|negotiated_algorithm,estimated_amount|UHC|COMMERCIAL,standard_charge|UHC|COMMERCIAL|methodology,additional_payer_notes|UHC|COMMERCIAL,standard_charge|UHC|MEDICARE|negotiated_dollar,standard_charge|UHC|MEDICARE|negotiated_percentage,standard_charge|UHC|MEDICARE|negotiated_algorithm,estimated_amount|UHC|MEDICARE,standard_charge|UHC|MEDICARE|methodology,additional_payer_notes|UHC|MEDICARE,standard_charge|WELLCARE|MEDICAID|negotiated_dollar,standard_charge|WELLCARE|MEDICAID|negotiated_percentage,standard_charge|WELLCARE|MEDICAID|negotiated_algorithm,estimated_amount|WELLCARE|MEDICAID,standard_charge|WELLCARE|MEDICAID|methodology,additional_payer_notes|WELLCARE|MEDICAID,standard_charge|WELLCARE|MEDICARE|negotiated_dollar,standard_charge|WELLCARE|MEDICARE|negotiated_percentage,standard_charge|WELLCARE|MEDICARE|negotiated_algorithm,estimated_amount|WELLCARE|MEDICARE,standard_charge|WELLCARE|MEDICARE|methodology,additional_payer_notes|WELLCARE|MEDICARE,standard_charge|min,standard_charge|max,additional_generic_notes
SWINGBED,1000006,CDM,110,RC,,,inpatient,,,530.52,318.31,,1273,100,,,per diem,100% Aetna inpatient per diem,1273,100,,,per diem,100% Aetna inpatient per diem,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,2598.72,100,,,per diem,100% Anthem inpatient per diem,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,2163,100,,,per diem,100% medical per diem. Per diem rate may vary depending on procedure,397.89,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,397.89,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,397.89,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,397.89,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at UHC DRG rates for inpatient setting. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,397.89,2598.72,
BB BLOOD BANK ORDER,1501702,CDM,111,RC,,,inpatient,,,,,,1273,100,,,per diem,100% Aetna inpatient per diem,1273,100,,,per diem,100% Aetna inpatient per diem,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,2598.72,100,,,per diem,100% Anthem inpatient per diem,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,2666,100,,,per diem,100% surgical per diem. Per diem rate may vary depending on procedure,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at UHC DRG rates for inpatient setting. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,1273,2666,
PRIVATE ROOM,1000002,CDM,111,RC,,,inpatient,,,772.5,463.5,,1273,100,,,per diem,100% Aetna inpatient per diem,1273,100,,,per diem,100% Aetna inpatient per diem,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,2598.72,100,,,per diem,100% Anthem inpatient per diem,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,2666,100,,,per diem,100% surgical per diem. Per diem rate may vary depending on procedure,579.38,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,579.38,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,579.38,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,579.38,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at UHC DRG rates for inpatient setting. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,579.38,2666,
REGULAR SUPPLIES,4006609,CDM,111,RC,,,inpatient,,,,,,1273,100,,,per diem,100% Aetna inpatient per diem,1273,100,,,per diem,100% Aetna inpatient per diem,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,2598.72,100,,,per diem,100% Anthem inpatient per diem,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,2666,100,,,per diem,100% surgical per diem. Per diem rate may vary depending on procedure,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at UHC DRG rates for inpatient setting. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,1273,2666,
PSYCH PRIVATE ROOM,,,114,RC,,,inpatient,,,978.5,587.1,,1018,100,,,per diem,100% Psych per diem,1018,100,,,per diem,100% Psych per diem,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,2598.72,100,,,per diem,100% Anthem inpatient per diem,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,2666,100,,,per diem,100% surgical per diem. Per diem rate may vary depending on procedure,733.88,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,733.88,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,733.88,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,733.88,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at UHC DRG rates for inpatient setting. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,733.88,2666,
ICU PRIVATE ROOM,1250001,CDM,200,RC,,,inpatient,,,1503.8,902.28,,1591,100,,,per diem,100% ICU per diem,1591,100,,,per diem,100% ICU per diem,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,2535.23,100,,,per diem,100% Anthem ICU per diem,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,3662,100,,,per diem,100% icu per diem. Per diem rate may vary depending on procedure,1127.85,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,1127.85,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,1127.85,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,1127.85,75,,,percent of total billed charges,75% of total billed charges for inpatient setting,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at UHC DRG rates for inpatient setting. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,1127.85,3662,
NF-DALMANE CAPSULE 30MG,641,CDM,210,RC,,,inpatient,,,,,,1591,100,,,per diem,100% ICU per diem,1591,100,,,per diem,100% ICU per diem,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,2535.23,100,,,per diem,100% Anthem ICU per diem,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,3662,100,,,per diem,100% icu per diem. Per diem rate may vary depending on procedure,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Not separately reimbursable for inpatient setting due to charge amount,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at UHC DRG rates for inpatient setting. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,,,,,other,Pays at GA Medicaid DRG rates. See MS-DRG rows,,,,,other,Pays at CMS MS-DRG rates. See MS-DRG rows,1591,3662,
***DESIPRAMINE TAB 25MG,1401438,CDM,250,RC,,,outpatient,,,4.03,2.42,,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,3.63,
**ALPRAZOLAM*TAB. 1MG **,1402253,CDM,250,RC,,,outpatient,,,5.41,3.25,,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,4.87,
**AMANTADINE SYR. 50MG/5CC,1401591,CDM,250,RC,,,outpatient,,,4.88,2.93,,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,4.39,
**AMLODIPINE*5MG/BENAZEPRIL 10MG**,1402290,CDM,250,RC,,,outpatient,,,13.58,8.15,,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,12.22,
**ATENOLOL*TAB. 100MG **,1402240,CDM,250,RC,,,outpatient,,,7,4.2,,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,6.3,
**NAPROXEN DS TAB 550MG,1401012,CDM,250,RC,,,outpatient,,,6.9,4.14,,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,6.21,
ACETAMINOPHEN (TYLENOL ) 120MG SUPP,1401337,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ACETAMINOPHEN (TYLENOL) 160MG/5ML DROP,1400622,CDM,250,RC,,,outpatient,,,25.13,15.08,,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,22.62,
ACETAMINOPHEN (TYLENOL) 325MG (5GR) SUPP,1401343,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ACETAMINOPHEN (TYLENOL) 325MG TAB,1402212,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ACETAMINOPHEN (TYLENOL) 325MG/10.15ML EL,1402207,CDM,250,RC,,,outpatient,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,6.63,
ACETAMINOPHEN (TYLENOL) 500MG TAB,1402214,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ACETAMINOPHEN (TYLENOL) 650MG SUPP,1400677,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ACETAMINOPHEN EL. 160MG/5CC,1400678,CDM,250,RC,,,outpatient,,,3.72,2.23,,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,3.35,
ACETAMINOPHEN ES LIQ. 500MG/15CC,1400764,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
ACETAMINOPHEN W/CODEINE #4,1400676,CDM,250,RC,,,outpatient,,,7.43,4.46,,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,6.69,
ACETAMINOPHEN(TYLENOL) W/CODEINE #3 TAB,1400675,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ACETAZOLAMIDE (DIAMOX) 250MG TABLET,5528,CDM,250,RC,,,outpatient,,,4.64,2.78,,3.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.18,
ACETYLCYSTEINE (MUCOMYST) 10% 4ML RESP,1402224,CDM,250,RC,,,outpatient,,,32.51,19.51,,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,29.26,
ACETYLCYSTEINE (MUCOMYST) 20% 30ML PO,1402015,CDM,250,RC,,,outpatient,,,111.18,66.71,,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,100.06,
ACETYLCYSTEINE 20% ORAL SOLN,1401272,CDM,250,RC,,,outpatient,,,26.18,15.71,,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.36,23.56,
ACTIVATED CHARCOAL(ACTIDOSE)/SORB 50G,1401344,CDM,250,RC,,,outpatient,,,76.93,46.16,,57.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.76,69.24,
ACYCLOVIR (ZOVIRAX) 200MG CAP,1400016,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ACYCLOVIR (ZOVIRAX) 5% OINT 15GM,1403961,CDM,250,RC,,,outpatient,,,249.19,149.51,,186.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.06,224.27,
ACYCLOVIR OINT 5% 3GM,1401614,CDM,250,RC,,,outpatient,,,73.1,43.86,,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.98,65.79,
ADVAIR 100/50 INHALER,1402493,CDM,250,RC,,,outpatient,,,426.21,255.73,,319.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,319.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,268.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.33,383.59,
ADVAIR 250/50 INHALER,1402330,CDM,250,RC,,,outpatient,,,520.11,312.07,,390.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,390.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,390.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,327.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.57,468.1,
ADVAIR 500/50 INHALER,1402467,CDM,250,RC,,,outpatient,,,734.94,440.96,,551.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,551.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,661.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,551.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,463.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.59,661.45,
AGGRENOX CAP 25MG/200MG,1402710,CDM,250,RC,,,outpatient,,,11.67,7,,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,10.5,
ALBUTEROL (PROVENTIL) 2.5MG/3ML NEBS,1401433,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ALBUTEROL HFA INH,5180,CDM,250,RC,,,outpatient,,,222.79,133.67,,167.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,167.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,140.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.65,200.51,
ALBUTEROL HFA INH,1404629,CDM,250,RC,,,outpatient,,,144.79,86.87,,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,91.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,130.31,
ALBUTEROL ORAL INHALER,1400944,CDM,250,RC,,,outpatient,,,135.37,81.22,,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.74,121.83,
ALFENTAMIL INJ 500 MCG,1401567,CDM,250,RC,,,outpatient,,,266.92,160.15,,200.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.69,240.23,
ALLOPURINOL (ZYLOPRIM) 100MG TAB,1400729,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ALLOPURINOL TAB. 300MG,1400730,CDM,250,RC,,,outpatient,,,3.08,1.85,,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.77,
ALPHAGEN P OPHTH SOLN 0.15%,1402335,CDM,250,RC,,,outpatient,,,148.63,89.18,,111.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,133.77,
ALPRAZOLAM (XANAX) 0.25MG TAB,1401158,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ALPRAZOLAM (XANAX) 0.5 MG TAB,1400908,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ALUMINUM CHORIDE (DRYSOL) 37.5ML,1404727,CDM,250,RC,,,outpatient,,,25.75,15.45,,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,23.18,
AMANTADINE (SYMMETREL) 100MG CAP,1400608,CDM,250,RC,,,outpatient,,,5.86,3.52,,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,5.27,
AMINO ACID 3%/GLYCERIN 3%,1401795,CDM,250,RC,,,outpatient,,,317.53,190.52,,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,200.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.06,285.78,
AMINOCAPROIC ACID (AMICAR) 250MG/ML 20ML,1404015,CDM,250,RC,,,outpatient,,,28.96,17.38,,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,26.06,
AMINOPHYLLINE 500MG/D5W 500ML,1402741,CDM,250,RC,,,outpatient,,,27.06,16.24,,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,24.35,
AMIODARONE (CORDARONE) 200MG TAB,1401383,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMITRIPTYLINE (ELAVIL) 10MG TAB,1401053,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMITRIPTYLINE (ELAVIL) 25MG TAB,1400201,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMLODIPINE (NORVASC) 5MG TAB,1401893,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMLODIPINE TAB. 10MG,1401987,CDM,250,RC,,,outpatient,,,8.91,5.35,,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,8.02,
AMLODIPINE*5MG/BENAZEPRIL 20MG**,1402291,CDM,250,RC,,,outpatient,,,14.33,8.6,,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,12.9,
AMMONIA INHALANT AMP,1401191,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMOX/CLAV (AUGMENTIN) 250MG/5ML (1ML) ER,1402633,CDM,250,RC,,,outpatient,,,4.78,2.87,,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,4.3,
AMOX/CLAV (AUGMENTIN) 250MG/5ML SUSP,1400305,CDM,250,RC,,,outpatient,,,201.33,120.8,,151,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,181.2,
AMOXICILLIN (AMOXIL) 250MG CAP,1400069,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMOXICILLIN (AMOXIL)125/5ML 100ML SUSP,1400327,CDM,250,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
AMOXICILLIN SUSP 125MG/5ML UD,1401928,CDM,250,RC,,,outpatient,,,9.76,5.86,,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,8.78,
AMOXICILLIN TAB*875MG **,1402374,CDM,250,RC,,,outpatient,,,6.47,3.88,,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,5.82,
AMOXICILLIN(AMOXIL)250MG/5ML SUSP ER 1ML,1402634,CDM,250,RC,,,outpatient,,,1.6,0.96,,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,1.44,
AMOXICILLIN/CLAV (AUGMENTIN) 250/125 TAB,1401429,CDM,250,RC,J3490,HCPCS,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMOXICILLIN/CLAV (AUGMENTIN) 500/125 TAB,1404628,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMOXICILLIN/CLAV (AUGMENTIN) 875/125 TAB,3777,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMOXICILLIN/CLAVULANATE TAB. 500MG,1401005,CDM,250,RC,,,outpatient,,,18.57,11.14,,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.71,
AMPICILLIN (PRINCIPEN) 125MG/5ML SUSP ER,1402632,CDM,250,RC,,,outpatient,,,1.6,0.96,,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,1.44,
AMPICILLIN (PRINCIPEN) 500MG CAP,1400061,CDM,250,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
AMPICILLIN (PRINCIPEN)125MG/5ML SUSP,1401389,CDM,250,RC,,,outpatient,,,28.41,17.05,,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,25.57,
AMPICILLIN 125MG INJ (VIAL),1401569,CDM,250,RC,,,outpatient,,,19.89,11.93,,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,17.9,
AMPICILLIN 1GM VIAL,1400064,CDM,250,RC,J0290,HCPCS,outpatient,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,11.32,
AMPICILLIN CAP 500MG,4359,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
AMPICILLIN SUSP 250MG/5ML,1400063,CDM,250,RC,,,outpatient,,,51.08,30.65,,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,45.97,
AMPICILLIN SUSP 250MG/5ML (1ML) ER ONLY,1403997,CDM,250,RC,,,outpatient,,,1.6,0.96,,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,1.44,
APAP (TYENOL) W/CODEINE 5ML UD,1401269,CDM,250,RC,,,outpatient,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,6.15,
APIXABAN (ELIQUIS) 5MG TAB,1404602,CDM,250,RC,,,outpatient,,,32.78,19.67,,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,29.5,
AQUAPHOR HEALING OINTMENT,5243,CDM,250,RC,,,outpatient,,,6.45,3.87,,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,5.81,
ARIPIPRAZOLE (ABILIFY) 10MG TAB,1402227,CDM,250,RC,,,outpatient,,,28.98,17.39,,21.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,26.08,
ARIPIPRAZOLE (ABILIFY) 2MG TAB,5513,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ARTIFICIAL TEARS 15ML,1401838,CDM,250,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
ASCORBIC ACID (VITAMIN C) 500MG TAB,1400714,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ASPIRIN 325MG TAB,1402344,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ASPIRIN 81MG 36CT BOTTLE,5520,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ASPIRIN 81MG TAB,1401543,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ASPIRIN EC (ECOTRIN) 325MG TAB,1400907,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ASPIRIN EC (ECOTRIN) 81MG TAB,1402215,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ASPIRIN SUPP 300MG,1400089,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
ASPIRIN SUPP 600MG,1401351,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
ASPIRIN TAB 325MG,1400090,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
ATENOLOL (TENORMIN) 50MG TAB,1400960,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ATENOLOL TAB. 25MG,1402292,CDM,250,RC,,,outpatient,,,5.09,3.05,,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,4.58,
ATORVASTATIN (LIPITOR) 10MG TAB,1402121,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ATORVASTATIN (LIPITOR) 40MG TAB,1404701,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ATORVASTATIN CAL. 20MG,1402055,CDM,250,RC,,,outpatient,,,15.49,9.29,,11.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,13.94,
ATRACURIUM BESYLATE INJ,1401756,CDM,250,RC,,,outpatient,,,69.39,41.63,,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.22,62.45,
ATROPINE SULF (ISOPTO)1% OPHTH SOLN 5ML,1401319,CDM,250,RC,,,outpatient,,,192.32,115.39,,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,173.09,
ATROVENT HFA INH,5661,CDM,250,RC,,,outpatient,,,822.52,493.51,,616.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,658.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,616.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,616.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,616.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,518.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.53,740.27,
AURALGAN OTIC SOLN,1400101,CDM,250,RC,,,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
AURALGAN OTIC SOLN (APPL) (ER USE),1402654,CDM,250,RC,,,outpatient,,,3.55,2.13,,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,3.2,
AZATHIOPRINE ORAL TABLET 50MG,3690,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
AZITHROMYCIN (ZITHROMAX) 100MG/5ML SUSP,1401998,CDM,250,RC,,,outpatient,,,104.63,62.78,,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.44,94.17,
AZITHROMYCIN (ZITHROMAX) 200MG/5ML SUSP,1402011,CDM,250,RC,,,outpatient,,,26.22,15.73,,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,23.6,
AZITHROMYCIN (ZITHROMAX) 250MG TAB,1402002,CDM,250,RC,,,outpatient,,,7.48,4.49,,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,6.73,
AZTREONAM (AZACTAM) 1GM VIAL,1401956,CDM,250,RC,,,outpatient,,,171.28,102.77,,128.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,107.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.1,154.15,
AZTREONAM (AZACTAM) 2GM VIAL,1402460,CDM,250,RC,,,outpatient,,,275.92,165.55,,206.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,206.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,206.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,173.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.54,248.33,
Bacitracin Oint,1401325,CDM,250,RC,,,outpatient,,,47.27,28.36,,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,42.54,
BACITRACIN OINT 1 GRAM PACKET,1400997,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BACLOFEN (LIORISAL) 10MG TAB,1401092,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BACTERIOSTATIC WATER FOR INJ,1401184,CDM,250,RC,,,outpatient,,,65.84,39.5,,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.49,59.26,
BD ULTRA-FINE II INSULIN SYRINGE 1/2 IN,1402399,CDM,250,RC,,,outpatient,,,72.56,43.54,,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,65.3,
BECLOMETHASONE AQ NASAL SPRAY,1401668,CDM,250,RC,,,outpatient,,,378.22,226.93,,283.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,283.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,283.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,238.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.5,340.4,
BECLOMETHASONE NASAL INHALER 7GM,1401289,CDM,250,RC,,,outpatient,,,157.12,94.27,,117.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,98.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.19,141.41,
BECLOMETHASONE ORAL INHALER 17GM,1400688,CDM,250,RC,,,outpatient,,,262.58,157.55,,196.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,165.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.8,236.32,
BENZOCAINE/MENTHOL (CEPACOL) LOZENGES,1400971,CDM,250,RC,,,outpatient,,,0.96,0.58,,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,0.86,
BENZOCAINE/MENTHOL (CHLORASEPTIC) LOZ,1400156,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BENZOIN COMP,1402586,CDM,250,RC,,,outpatient,,,22.67,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,20.4,
BENZONATATE (TESSALON PERLES) 100MG CAP,1401577,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BENZTROPIN TAB 1MG,1401503,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
BENZTROPINE (COGENTIN) TAB 0.5MG,1400146,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BETAMETHASONE (VALISONE) 0.1% 15GM CR,1400685,CDM,250,RC,,,outpatient,,,78.24,46.94,,58.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.03,70.42,
BETAMETHASONE SOD. PHOS AND ACETATE,1403977,CDM,250,RC,,,outpatient,,,177.17,106.3,,132.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,111.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.3,159.45,
BETAXOLOL OPHTH SUSP 0.25%,1401989,CDM,250,RC,,,outpatient,,,199.18,119.51,,149.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.81,179.26,
BICILLIN CR 1.2 MIL UNITS,1402624,CDM,250,RC,,,outpatient,,,570.5,342.3,,427.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,513.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,427.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,359.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.9,513.45,
BISACODYL (DULCOLAX) 10MG SUPP,1400195,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BISACODYL (DULCOLAX) 5MG TAB,1400194,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BISMUTH SUBSALICYLATE (PEPTO BISMOL) TAB,1402165,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BISMUTH SUBSALICYLATE SUSP,1401260,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BISOPROLOL (ZEBETA) 5MG TABLET,1404649,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BISOPROLOL FUMARATE 2.5/H-THIAZIDE 6.25,1402074,CDM,250,RC,,,outpatient,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,6.63,
BISOPROLOL FUMURATE 10MG/HCTZ6.25MG,1402382,CDM,250,RC,,,outpatient,,,11.47,6.88,,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,10.32,
BISOPROLOL FUMURATE 5MG/HCTZ 6.25MG,1402088,CDM,250,RC,,,outpatient,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,6.63,
BRIMONIDINE(ALPHAGAN-P)0.15%OPHTH SOL5ML,1402451,CDM,250,RC,,,outpatient,,,212.26,127.36,,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,133.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.49,191.03,
BRINZOLAMIDE OPHTH SUSP 1%,1402452,CDM,250,RC,,,outpatient,,,156.69,94.01,,117.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,98.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.11,141.02,
BRONCHODILATOR 0.25M,2600047,CDM,250,RC,,,outpatient,,,8.7,5.22,,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,7.83,
BUDESONIDE (PULMICORT) 0.5MG/2ML NEBS,1402714,CDM,250,RC,,,outpatient,,,20.49,12.29,,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,18.44,
BUMETANIDE (BUMEX) 0.25MG/ML INJ 10ML,1404656,CDM,250,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
BUMETANIDE (BUMEX) 0.25MG/ML INJ 4ML,1402755,CDM,250,RC,,,outpatient,,,8.2,4.92,,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,7.38,
BUMETANIDE (BUMEX) TAB 1MG,1401595,CDM,250,RC,,,outpatient,,,5.77,3.46,,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.19,
BUPIVACAINE (MARCAINE) 0.25% (PF) 10ML,1402042,CDM,250,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
BUPIVACAINE (MARCAINE) 0.25% 30ML,1402112,CDM,250,RC,,,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.54,
BUPIVACAINE (MARCAINE) 0.5% (PF) 10ML,1404622,CDM,250,RC,,,outpatient,,,15.46,9.28,,11.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,13.91,
BUPIVACAINE (MARCAINE) 0.5% (PF) 30ml,1404687,CDM,250,RC,,,outpatient,,,7.16,4.3,,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,6.44,
BUPIVACAINE 0.25% W/EPI 30ML,1402199,CDM,250,RC,,,outpatient,,,41.64,24.98,,31.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.53,37.48,
BUPIVACAINE 0.5% W/EPINEPHRINE 1:200000,1401891,CDM,250,RC,,,outpatient,,,45.09,27.05,,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.24,40.58,
BUPIVACAINE INJ 0.25% (PF) 30ML,1401946,CDM,250,RC,,,outpatient,,,31.3,18.78,,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,28.17,
BUPIVACAINE INJ 0.50% 50ML,1402778,CDM,250,RC,,,outpatient,,,35.28,21.17,,26.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.23,31.75,
BUPIVACAINE-MPF (MARCAINE-MPF) 0.5% 30ML,1401219,CDM,250,RC,,,outpatient,,,33.95,20.37,,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.96,30.56,
BUPIVACAINE-MPF SOLN 0.50% 25ML/NS 75ML,1402221,CDM,250,RC,,,outpatient,,,42.17,25.3,,31.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,37.95,
BUPIVACAINE/DEX (MARCAINE) 0.75% SPINAL,1402035,CDM,250,RC,,,outpatient,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,15.25,
BUPROPION (WELLBUTRIN) 75MG TAB,1401682,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BUPROPION SR (WELLBUTRIN SR) 150MG,1402056,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BUSPIRONE (BUSPAR) 10MG TAB,1404615,CDM,250,RC,,,outpatient,,,4.27,2.56,,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.84,
BUSPIRONE (BUSPAR) 5MG TAB,1401025,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
BUSPIRONE TAB 10MG,1401024,CDM,250,RC,,,outpatient,,,6.47,3.88,,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,5.82,
BUTT PASTE COMPOUND,1404598,CDM,250,RC,,,outpatient,,,68.96,41.38,,51.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.13,62.06,
CALCITONIN-SALMON (MIACALCIN 200UN/DS NS,1402059,CDM,250,RC,,,outpatient,,,81.96,49.18,,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,73.76,
CALCITONIN-SALMON 200IU INJ.,1400766,CDM,250,RC,,,outpatient,,,118.5,71.1,,88.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.28,106.65,
CALCITRIOL (ROCALTROL) 0.25MCG CAP,1400879,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CALCIUM ACETATE (PHOS LO) 667MG TAB,1401824,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CALCIUM CARB+VIT D (OSCAL+D) 250/125 TAB,1400463,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CALCIUM CARBONATE (TUMS) 500MG TAB,1400745,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CALCIUM GLUCONATE TAB 500MG,1401108,CDM,250,RC,,,outpatient,,,4.03,2.42,,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,3.63,
CANDIDA FOR CONTROL TEST,1403975,CDM,250,RC,,,outpatient,,,21.86,13.12,,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,19.67,
CARBACHOL(MIOSTAT) OPHTH SOLN 0.01%1.5ML,1402114,CDM,250,RC,,,outpatient,,,155.45,93.27,,116.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.85,139.91,
CARBAMAZEPINE (TEGRETOL) 200MG TAB,1400844,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CARBAMIDE PEROXIDE (DEBROX) 15ML,1400147,CDM,250,RC,,,outpatient,,,25.95,15.57,,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,23.36,
CARBAMIDE PEROXIDE 15ML,1402590,CDM,250,RC,,,outpatient,,,25.95,15.57,,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,23.36,
CARBIDOPA/LEVODOPA (SINEMET) 10/100 TAB,1400563,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CARBIDOPA/LEVODOPA (SINEMET) 25/100 TAB,1401140,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CARBOPROST (HEMABATE) 250MCG INJ,1402456,CDM,250,RC,,,outpatient,,,887.02,532.21,,665.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,665.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,798.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,665.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,558.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.75,798.32,
CARDEC-DM DROPS,1400896,CDM,250,RC,,,outpatient,,,124.13,74.48,,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.43,111.72,
CARISOPRODOL 350MG TABLET,1400572,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
CARVEDILOL (COREG) 12.5MG TAB,1402048,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CARVEDILOL (COREG) 3.125MG TAB,1402047,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CATHFLO 2MG INJ,1402680,CDM,250,RC,,,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,221.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,315.94,
CEFDINIR (OMNICEF) 125MG/5ML SUSP,1402193,CDM,250,RC,,,outpatient,,,98.14,58.88,,73.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.11,88.33,
CEFDINIR (OMNICEF)125MG/5ML SUSP ER USE,1402640,CDM,250,RC,,,outpatient,,,3,1.8,,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,2.7,
CEFDINIR CAP 300MG,1402192,CDM,250,RC,,,outpatient,,,34.69,20.81,,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,31.22,
CEFIXIME TAB. 400MG,1401809,CDM,250,RC,,,outpatient,,,74.8,44.88,,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.33,67.32,
CEFOTETAN 2000MG INJ. (VIAL),1403979,CDM,250,RC,,,outpatient,,,125.98,75.59,,94.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,113.38,
CEFOTETAN:2000MG/D5W 50ML PREMIXED,1404008,CDM,250,RC,,,outpatient,,,112.46,67.48,,84.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.04,101.21,
CEFOXITIN 2GM/D5W 50ML PREMIX,1401865,CDM,250,RC,,,outpatient,,,89.65,53.79,,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,80.69,
CEFOXITIN:1GM/D5W 50ML (FROZEN),1401857,CDM,250,RC,,,outpatient,,,58.77,35.26,,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.04,52.89,
CEFPROZIL SUSP 125MG/5ML,1401936,CDM,250,RC,,,outpatient,,,155.16,93.1,,116.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,139.64,
CEFUROXIME (CEFTIN) 250MG TAB,1401496,CDM,250,RC,,,outpatient,,,24.13,14.48,,18.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,21.72,
CEFUROXIME SUSP 125MG/5ML,1402028,CDM,250,RC,,,outpatient,,,223.19,133.91,,167.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,167.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,140.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.73,200.87,
CELECOXIB (CELEBREX) 100MG CAP,1402089,CDM,250,RC,,,outpatient,,,4.48,2.69,,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,4.03,
CELECOXIB CAP 200MG,1402278,CDM,250,RC,,,outpatient,,,16.34,9.8,,12.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,14.71,
CEPASTAT LOZENGES,1401780,CDM,250,RC,,,outpatient,,,0.96,0.58,,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,0.86,
CEPHALEXIN (KEFLEX) 125MG/5ML 100ML SUSP,1400313,CDM,250,RC,,,outpatient,,,10.11,6.07,,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,9.1,
CEPHALEXIN (KEFLEX) 125MG/5ML SUSP ER,1402636,CDM,250,RC,,,outpatient,,,2.91,1.75,,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,2.62,
CEPHALEXIN (KEFLEX) 250MG CAP,1400315,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CETACAINE SPRAY 20GM,1401283,CDM,250,RC,,,outpatient,,,113.37,68.02,,85.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.23,102.03,
CHERRY SYRUP,1404661,CDM,250,RC,,,outpatient,,,96.71,58.03,,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,87.04,
CHLORDIAZEPOXIDE (LIBRIUM) 10MG CAP,1400339,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CHLORDIAZEPOXIDE/CLINDINIUM BROMIDE CAP,1400337,CDM,250,RC,,,outpatient,,,3.08,1.85,,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.77,
CHLOROPROCAINE HCL INJ 2% 30ML,1401590,CDM,250,RC,,,outpatient,,,121.85,73.11,,91.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.97,109.67,
CHLOROPROCAINE HCL INJ 3% 30ML,1400444,CDM,250,RC,,,outpatient,,,124.13,74.48,,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.43,111.72,
CHLORPROMAZINE (THORAZINE) 25MG TAB,1400646,CDM,250,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
CHLORPROPAMIDE TAB 250MG,1400173,CDM,250,RC,,,outpatient,,,4.46,2.68,,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,4.01,
CHLORTHALIDONE (HYGROTON) 50MG TAB,1400263,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CHOLECALCIFEROL (VITAMIN D3) 1000U TAB,1404596,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CHOLESTYRAMINE (QUESTRAN) 4G PWD,1401390,CDM,250,RC,,,outpatient,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,11.32,
CHROMAGEN CAP,1400996,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
CICLOPIROX (LOPROX) 0.77% CREAM 15G,1400058,CDM,250,RC,,,outpatient,,,269.37,161.62,,202.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.19,242.43,
CILOSTAZOL (PLETAL) 100MG TAB,1402138,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CIPROFLOXACIN (CILOXIN) 0.3% OPHTH SOLN,1402223,CDM,250,RC,,,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,26.8,
CIPROFLOXACIN (CIPRO) 250MG TAB,1401518,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CIPROFLOXACIN (CIPRO) 400MG/200 D5W PM,1401898,CDM,250,RC,J0744,HCPCS,outpatient,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.1,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,10.82,
CIPROFLOXACIN (CIPRO) 750MG TAB,1402064,CDM,250,RC,,,outpatient,,,32.78,19.67,,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,29.5,
CIPROFLOXACIN 500MG,1401018,CDM,250,RC,,,outpatient,,,21.32,12.79,,15.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,19.19,
CIPROFLOXACIN HCL OPHTH OINT 0.3%,1402116,CDM,250,RC,,,outpatient,,,301.87,181.12,,226.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,190.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.85,271.68,
CIPROFLOXACIN: 200MG INJ (VIAL),1401687,CDM,250,RC,,,outpatient,,,69.39,41.63,,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.22,62.45,
CIPROFLOXACIN*XR TAB 500MG*,1402337,CDM,250,RC,,,outpatient,,,48.8,29.28,,36.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,43.92,
CISATRACURIUM 2MG/ML INJ,1402500,CDM,250,RC,,,outpatient,,,85.23,51.14,,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.46,76.71,
CITALOPRAM (CELEXA) 10MG TAB,1402709,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CLINDAMYCIN (CLEOCIN) 150MG CAP,1402160,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CLINDAMYCIN (CLEOCIN) 600MG/D5W 50ML PB,1401948,CDM,250,RC,,,outpatient,,,43.17,25.9,,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,38.85,
CLINDAMYCIN (CLEOCIN) 75MG/5ML OS 100ML,1404685,CDM,250,RC,,,outpatient,,,46.68,28.01,,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,42.01,
CLINDAMYCIN (CLEOCIN) 900MG/D5W 50ML PB,1401952,CDM,250,RC,,,outpatient,,,58.46,35.08,,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,52.61,
CLINDAMYCIN 75MG/5ML (100ML),1402760,CDM,250,RC,,,outpatient,,,202.36,121.42,,151.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.46,182.12,
CLINDAMYCIN VAGCREAM 2%,1402612,CDM,250,RC,,,outpatient,,,226.47,135.88,,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,203.82,
CLINDAMYCIN: 300MG INJ (VIAL),1400135,CDM,250,RC,S0077,HCPCS,outpatient,,,21.75,13.05,,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.72,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.72,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.91,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.73,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,19.58,
CLINDAMYCIN: 600MG INJ (VIAL),1402751,CDM,250,RC,,,outpatient,,,36.62,21.97,,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,32.96,
CLINDAMYCIN(CLEOCIN) 300MG/D5W 50ML IVPB,1402025,CDM,250,RC,,,outpatient,,,29.5,17.7,,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,26.55,
CLINDAMYCIN*PHOSPHATE GEL 1% 40ML**,1402326,CDM,250,RC,,,outpatient,,,160.3,96.18,,120.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.85,144.27,
CLINIMIX 4.25/5 1000ML,1402732,CDM,250,RC,,,outpatient,,,93.43,56.06,,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.14,84.09,
CLINIMIX E 4.25/10 1000ML,1404678,CDM,250,RC,,,outpatient,,,193.88,116.33,,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,122.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.73,174.49,
CLONAZEPAM (KLONOPIN) 1MG TABLET,1402333,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CLONIDINE (CATAPRES) 0.1MG TAB,1400128,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CLONIDINE (CATAPRES) 0.1MG/24HR PATCH,1401497,CDM,250,RC,,,outpatient,,,76.49,45.89,,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,68.84,
CLONIDINE (CATAPRES) 0.2MG/24HR PATCH,1401597,CDM,250,RC,,,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,108.18,
CLOPIDOGREL BISULFATE (PLAVIX) 75MG TAB,1402090,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CLORAZEPATE TAB 7.5MG,1401492,CDM,250,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
CLOTRIM/BETAMETH (LOTRISONE) 1/0.05% CR,1401334,CDM,250,RC,,,outpatient,,,87.42,52.45,,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,78.68,
CLOTRIMAZOLE (LOTRIMIN) 1% 15 GM CREAM,1400357,CDM,250,RC,,,outpatient,,,9.79,5.87,,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,8.81,
CLOZAPINE (CLOZARIL) 25MG TABLET,5815,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CLOZAPINE (CLOZARIL) 50MG TABLET,5807,CDM,250,RC,,,outpatient,,,5.84,3.5,,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,5.26,
CLOZAPINE TAB. 100MG,1401931,CDM,250,RC,,,outpatient,,,17.51,10.51,,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,15.76,
COLCHICINE 0.6MG TABLET,3861,CDM,250,RC,,,outpatient,,,28.43,17.06,,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,25.59,
COLCHICINE INJ 1MG/2ML,1401767,CDM,250,RC,,,outpatient,,,46.26,27.76,,34.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.48,41.63,
COLCHICINE/PROBENECID (COLBENEMID) TAB,1400124,CDM,250,RC,,,outpatient,,,5.3,3.18,,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,4.77,
COLLAGENASE (SANTYL) 250U/GM OINTMENT,3736,CDM,250,RC,,,outpatient,,,511.4,306.84,,383.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,383.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,383.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,322.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.79,460.26,
COLYTE,1402558,CDM,250,RC,,,outpatient,,,123.48,74.09,,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,111.13,
COMBIVENT RESPIMAT INH 100MCG-20MCG/A,3646,CDM,250,RC,,,outpatient,,,729.94,437.96,,547.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,583.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,547.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,547.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,459.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.56,656.95,
CONJUGATED ESTROGEN TAB 0.3MG,1401125,CDM,250,RC,,,outpatient,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,6.15,
CONJUGATED ESTROGEN TAB 0.625MG,1400508,CDM,250,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
CONJUGATED ESTROGEN TAB 1.25MG,1401406,CDM,250,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
CONJUGATED ESTROGEN VAG CREAM,1400509,CDM,250,RC,,,outpatient,,,349.13,209.48,,261.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,261.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,261.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,219.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.54,314.22,
CORTISPORIN OPHTH SUSP,1400144,CDM,250,RC,,,outpatient,,,266.35,159.81,,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,167.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,239.72,
CORTISPORIN OTIC SOLN 10ML,1400143,CDM,250,RC,,,outpatient,,,148.61,89.17,,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,133.75,
CORTISPORIN OTIC SUSP 10ML,1401636,CDM,250,RC,,,outpatient,,,148.61,89.17,,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,133.75,
CROMOLYN SODIUM NASAL SPRAY,1401618,CDM,250,RC,,,outpatient,,,46.68,28.01,,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.56,42.01,
CROMOLYN SODIUM SOLN 20MG/2,1402013,CDM,250,RC,,,outpatient,,,9.28,5.57,,6.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,8.35,
CROTALIDAE POLYVALENT (OVINE),1402461,CDM,250,RC,,,outpatient,,,5995.68,3597.41,,4496.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4796.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1277.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1277.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1289.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5396.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4496.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4496.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4496.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4496.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1228.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3777.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1228.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1228.51,5396.11,
CYANOCOBALAMIN (VITAMIN B12) 500MCG TAB,1401378,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CYCLOBENZAPRINE (FLEXERIL) 10MG TAB,1400229,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CYCLOPENTOLATE/PHENYL/ (CYCLOMYDRIL) OS,1402113,CDM,250,RC,,,outpatient,,,125.94,75.56,,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,113.35,
CYPROHEPTADINE (PERIACTIN)2MG/5ML SYRUP,1402592,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
CYPROHEPTADINE HCL (PERIACTIN) 4MG TAB,1400478,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
CYPROHEPTADINE*HCL SYRUP 2MG/5ML**,1402276,CDM,250,RC,,,outpatient,,,2.12,1.27,,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,1.91,
D5 1/2 NS 1L/PITOCIN 20 UNITS IV,1402794,CDM,250,RC,,,outpatient,,,57.64,34.58,,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,51.88,
DANTROLENE INJ 20MG,1401852,CDM,250,RC,,,outpatient,,,309.24,185.54,,231.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,231.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,231.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,194.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.36,278.32,
DAPTOMYCIN (CUBICIN) 500MG/100ML NS IVPB,1404594,CDM,250,RC,,,outpatient,,,394.35,236.61,,295.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,295.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,295.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,248.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.8,354.92,
DERMOPLAST SPRAY 56GM,1400170,CDM,250,RC,,,outpatient,,,25.13,15.08,,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,22.62,
DESFLURANE (SUPRANE) 240ML,1402606,CDM,250,RC,,,outpatient,,,764.63,458.78,,573.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,611.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,573.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,573.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,481.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.67,688.17,
DESOXIMETASONE CREAM 0.25%,1400661,CDM,250,RC,,,outpatient,,,124.57,74.74,,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,112.11,
DEXAMETHASONE (DECADRON) 10MG/ML INJ,1403993,CDM,250,RC,,,outpatient,,,21.58,12.95,,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,19.42,
DEXAMETHASONE (DECADRON) 4MG TAB,1400817,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DEXAMETHASONE (DECADRON) 4MG/ML INJ,1400573,CDM,250,RC,J1094,HCPCS,outpatient,,,14.15,8.49,,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,12.74,
DEXAMETHASONE OPHTH OINT 0.05%,1401303,CDM,250,RC,,,outpatient,,,21.54,12.92,,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,19.39,
DEXTROSE 50% 0.5G/ML 50ML ABBJ,1400171,CDM,250,RC,,,outpatient,,,24.04,14.42,,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,21.64,
DEXTROSE 50% 0.5G/ML 50ML VIAL,1404732,CDM,250,RC,,,outpatient,,,103,61.8,,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.1,92.7,
DIAMOX 250MG,1400175,CDM,250,RC,,,outpatient,,,11.47,6.88,,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,10.32,
DIAZEPAM TAB 2MG,1401175,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
DIAZEPAM TAB 5MG,1400686,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DICLOFENAC (VOLTAREN) 1% GEL 100GM,1404593,CDM,250,RC,,,outpatient,,,123.42,74.05,,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.29,111.08,
DICLOFENAC 75MG/MISOPROSTOL 200MCG,1402262,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
DICYCLOMINE (BENTYL) 10MG CAP,1401027,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DIGOXIN (LANOXIN) 0.125MG TAB,1400743,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DIGOXIN 0.25MG TAB,1401071,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
DIHYDROERGOTAMINE MES INJ 1MG/ML,1404078,CDM,250,RC,,,outpatient,,,367.71,220.63,,275.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,275.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.34,330.94,
DILAUDID INJ 1MG/0.5ML (0.5ML),1404592,CDM,250,RC,J1170,HCPCS,outpatient,,,10.88,6.53,,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.29,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,9.79,
DILTIAZEM (CARDIZEM) 30MG TAB,1400970,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DILTIAZEM (CARDIZEM) 5MG/ML 25ML INJ,1403965,CDM,250,RC,,,outpatient,,,43.44,26.06,,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,39.1,
DILTIAZEM (CARDIZEM) 5MG/ML 5ML INJ,1402083,CDM,250,RC,,,outpatient,,,55.17,33.1,,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,49.65,
DILTIAZEM CD (CARDIZEM CD) 120MG CAP,1401897,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DILTIAZEM CD (CARDIZEM CD) 180MG CAP,1401870,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DILTIAZEM CD 240MG CAP.,1401871,CDM,250,RC,,,outpatient,,,7,4.2,,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.43,6.3,
DIMENHYDRINATE (DRAMAMINE) 50MG TAB,1400191,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
DINOPROSTONE 10MG VAG. INSERT,1402136,CDM,250,RC,,,outpatient,,,1073.61,644.17,,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,858.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,966.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,676.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.98,966.25,
DINOPROSTONE 20MG VAG INSERT,1402708,CDM,250,RC,,,outpatient,,,3257.69,1954.61,,2443.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2606.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,693.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2443.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,700.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2931.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2443.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2443.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2052.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.5,2931.92,
DIPHENHYDRAMINE (BENADRYL) 2% CREAM,1404650,CDM,250,RC,,,outpatient,,,13.67,8.2,,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,12.3,
DIPHENHYDRAMINE (BENADRYL) 25MG CAP,1400113,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DIPHENHYDRAMINE (BENADRYL) 50MG/ML INJ,1400112,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DIPHENHYDRAMINE (BENADRYL)12.5MG/5ML UD,1402478,CDM,250,RC,,,outpatient,,,9.55,5.73,,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
DIPHENHYDRAMINE 12.5MG/5ML BOTTLE,1401737,CDM,250,RC,,,outpatient,,,10.1,6.06,,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,9.09,
DIPHENHYDRAMINE CAP 50MG,1401028,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
DIPHENHYDRAMINE ELIX 12.5MG/5ML,1400737,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
DIPHENOXYLATE/ATROPINE (LOMOTIL) 2.5MG,1400350,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DIPHENOXYLATE/ATROPINE LIQ 2.5MG/5ML,1400351,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
DIPYRIDAMOLE (PERSANTINE) 25MG TAB,1400484,CDM,250,RC,,,outpatient,,,3.83,2.3,,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,3.45,
DISOPYRAMIDE CAP 150MG,1400456,CDM,250,RC,,,outpatient,,,5.52,3.31,,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,4.97,
DISOPYRAMIDE CR 150MG,1401885,CDM,250,RC,,,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.54,
DIVALPROEX (DEPAKOTE) ER 250MG TAB,1401615,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DIVALPROEX (DEPAKOTE) SPRINKLES 125MG,1402271,CDM,250,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
DIVALPROEX SODIUM SRTAB 125MG,1402169,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DNU NM PERSANTINE PER 10 MG,1600094,CDM,250,RC,J1245,HCPCS,outpatient,,,16.67,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,15,
DOCUSATE (COLACE) 100MG CAP,1401045,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DOCUSATE (COLACE) 100MG/10ML UD LIQUID,1404624,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DOCUSATE (COLACE) 60MG/15ML LIQUID,1400673,CDM,250,RC,,,outpatient,,,3.72,2.23,,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,3.35,
DOCUSATE/SENNA (PERICOLACE) 8.6/50MG TAB,1400479,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DONEPEZIL (ARICEPT) 5MG TAB,1402032,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DONNAGEL SUSP,1401810,CDM,250,RC,,,outpatient,,,12.41,7.45,,9.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.54,11.17,
DOPAMINE 400MG/500ML D5W PREMIX,1401602,CDM,250,RC,,,outpatient,,,56.28,33.77,,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,50.65,
DOPAMINE 400MG/D5W 250ML,1404607,CDM,250,RC,,,outpatient,,,88.05,52.83,,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.04,79.25,
DOPAMINE 800MG/250ML D5W PREMIX,1404740,CDM,250,RC,,,outpatient,,,71.59,42.95,,53.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,64.43,
DOPAMINE 800MG/D5W 500ML,1402471,CDM,250,RC,,,outpatient,,,44.34,26.6,,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,39.91,
DORZOLAMIDE/TIMOLOL(COSOPT)OPH SOLN 10ML,1402453,CDM,250,RC,,,outpatient,,,76.77,46.06,,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,69.09,
DOXAZOSIN MESYLATE (CARDURA) 1MG TAB,1401690,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DOXAZOSIN MESYLATE (CARDURA) 4MG TAB,1401881,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DOXEPIN (SINEQUAN) 25MG CAP,1400029,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
DOXEPIN CAP 10MG,1400030,CDM,250,RC,,,outpatient,,,3.08,1.85,,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.77,
DOXYCYCLINE (VIBRAMYCIN) 100MG TAB,1400697,CDM,250,RC,,,outpatient,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,6.15,
DOXYCYCLINE (VIBRAMYCIN) 100MG VIAL,1400699,CDM,250,RC,,,outpatient,,,59.82,35.89,,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.26,53.84,
DOXYCYCLINE100MG/NS 100ML IVPB,1402783,CDM,250,RC,,,outpatient,,,88.24,52.94,,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,79.42,
DRONABINOL (MARINOL) 2.5 MG CAPS,1404035,CDM,250,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
DROPERIDOL (INAPSINE) 2.5MG/ML 2ML INJ,1404706,CDM,250,RC,,,outpatient,,,35.55,21.33,,26.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,32,
DULOXETINE (CYMBALTA) 20MG CAP,4261,CDM,250,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
DULoxetine (CYMBALTA) 20MG CAPSULE,5559,CDM,250,RC,,,outpatient,,,29.62,17.77,,22.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.07,26.66,
DULOXETINE (CYMBALTA) 30MG CAP,1402476,CDM,250,RC,,,outpatient,,,5.3,3.18,,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,4.77,
DUTASTERIDE (AVODART) 0.5MG CAP,1402769,CDM,250,RC,,,outpatient,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,24.59,
EDROPHONIUM INJ 10MG/ML,1401176,CDM,250,RC,,,outpatient,,,73.52,44.11,,55.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.06,66.17,
ELDERTONIC ELIXIR,1401247,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
EMOLLIENT (KERI) LOTION 8 OZ,1400788,CDM,250,RC,,,outpatient,,,31.25,18.75,,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,28.13,
ENALAPRILAT (VASOTEC) 1.25MG/ML 2ML INJ,1401182,CDM,250,RC,,,outpatient,,,28.96,17.38,,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,26.06,
EPHEDRINE 50MG/ML INJ,1400209,CDM,250,RC,,,outpatient,,,117.74,70.64,,88.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.12,105.97,
EPINEPHRINE (ADRENALIN) 1MG/ML INJ 30ML,1401819,CDM,250,RC,,,outpatient,,,415.87,249.52,,311.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,311.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,311.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.21,374.28,
EPINEPHRINE 4MG/250ML D5W (16MCG/ML),1404670,CDM,250,RC,,,outpatient,,,92.06,55.24,,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,82.85,
ERTAPENEM (INVANZ) 1GM VIAL,1404066,CDM,250,RC,,,outpatient,,,339.02,203.41,,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,213.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,305.12,
ERYTHROMYCIN (ILOTYCIN) 5MG/GM OO 3.5GM,1400947,CDM,250,RC,,,outpatient,,,26.22,15.73,,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,23.6,
ERYTHROMYCIN 500MG VIAL,1402684,CDM,250,RC,,,outpatient,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,36.88,
ERYTHROMYCIN BASE 250MG,1401912,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
ERYTHROMYCIN BASE 500MG,1402008,CDM,250,RC,,,outpatient,,,8.76,5.26,,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.88,
ERYTHROMYCIN E.S./SULFISOXAZOLE SUSP.,1401499,CDM,250,RC,,,outpatient,,,140.83,84.5,,105.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.86,126.75,
ERYTHROMYCIN ETHYLSUCCINATE SUSP 200MG/5,1400216,CDM,250,RC,,,outpatient,,,679.95,407.97,,509.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,509.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,611.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,509.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,428.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.32,611.96,
ERYTHROMYCIN ETHYLSUCCINATE TAB 400MG,1400214,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
ERYTHROMYCIN STEARATE TAB 250MG,1400215,CDM,250,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
ESCITALOPRAM (LEXAPRO) 10MG TAB,1402216,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ESMOLOL (BREVIBLOC) 10MG/ML INJ 10ML,1402599,CDM,250,RC,,,outpatient,,,20.49,12.29,,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,18.44,
ESTRADIOL (ESTRACE) 1MG TAB,1402297,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ESTRADIOL TRANSDERMAL SYSTEM 0.1MG,1401641,CDM,250,RC,,,outpatient,,,53.82,32.29,,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.03,48.44,
ESTRADIOL*TRANSDERMAL SYS. 0.1MG CLIMARA,1402312,CDM,250,RC,,,outpatient,,,68.43,41.06,,51.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.02,61.59,
ESTROGEN*0.625MG/MEDROXYPROGESTERONE 5MG,1402324,CDM,250,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
ETHAMBUTOL TAB 400MG,1402266,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
ETHYL CHLORIDE SPRAY 103.5ML,1400219,CDM,250,RC,,,outpatient,,,114.46,68.68,,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.45,103.01,
ETHYL CHLORIDE SPRAY APPLICATION (ER),1402712,CDM,250,RC,,,outpatient,,,3.45,2.07,,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.71,3.11,
ETOMIDATE (AMIDATE) 2MG/ML 10ML INJ,1402692,CDM,250,RC,,,outpatient,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,11.32,
ETOMIDATE INJ 20MG (2MG/ML),1402038,CDM,250,RC,,,outpatient,,,227.45,136.47,,170.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,170.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.6,204.71,
EYE WASH SOLN 120ML,1400988,CDM,250,RC,,,outpatient,,,17.21,10.33,,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,15.49,
EYE-VITES (OCUVITE) TABLET,2965,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
EZETIMIBE TAB 10MG,1402562,CDM,250,RC,,,outpatient,,,16.18,9.71,,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,14.56,
EZETIMIBE*TAB 10MG**,1402274,CDM,250,RC,,,outpatient,,,19.36,11.62,,14.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,17.42,
F,5150,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FAMOTIDINE (PEPCID) 10MG/ML 2ML INJ,1402082,CDM,250,RC,,,outpatient,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.17,
FAMOTIDINE (PEPCID) 20MG TAB,1401119,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FAMOTIDINE (PEPCID) 20MG/NS 50ML IVPB,1402106,CDM,250,RC,,,outpatient,,,19.67,11.8,,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,17.7,
FAT EMULSION (LIPIDS) 20% 250ML IVPB,1404700,CDM,250,RC,,,outpatient,,,93.15,55.89,,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.09,83.84,
FAT EMULSION IV 20% 500ML,1401796,CDM,250,RC,,,outpatient,,,93.15,55.89,,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.09,83.84,
FELODIPINE 5MG TAB,1402603,CDM,250,RC,,,outpatient,,,12.73,7.64,,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,11.46,
FENOFIBRATE (TRICOR) 145MG TAB,1402320,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FENOFIBRATE (TRICOR) 48MG TAB,1402703,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FENTANYL (DURAGESIC) 100MCG/HR PATCH,1402007,CDM,250,RC,,,outpatient,,,38.24,22.94,,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,34.42,
FENTANYL (DURAGESIC) 12MCG/HR PATCH,1402679,CDM,250,RC,,,outpatient,,,13.67,8.2,,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,12.3,
FENTANYL (DURAGESIC) 25MCG/HR PATCH,1401889,CDM,250,RC,,,outpatient,,,30.87,18.52,,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,27.78,
FENTANYL (DURAGESIC) 50MCG/HR PATCH,1402195,CDM,250,RC,,,outpatient,,,35.51,21.31,,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,31.96,
FENTANYL (DURAGESIC) 75MCG/HR PATCH,1402006,CDM,250,RC,,,outpatient,,,83.59,50.15,,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,75.23,
FENTANYL (SUBLIMAZE) 50MCG/ML 5ML INJ,1401957,CDM,250,RC,,,outpatient,,,7.92,4.75,,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,7.13,
FENTANYL 200MCG/BUP. 0.5% 25ML/NS 71ML,1402222,CDM,250,RC,,,outpatient,,,487.35,292.41,,365.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,389.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,365.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,365.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,307.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.86,438.62,
FENTANYL CITRATE INJ SOLUTION 0.05MG/1ML,1404591,CDM,250,RC,,,outpatient,,,3,1.8,,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,2.7,
FERROUS GLUCONATE TAB 5 GR.,1401574,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
FERROUS SULFATE 300MG/5ML ELIXER,1401248,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FERROUS SULFATE 325MG TAB,1400223,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FINASTERIDE (PROSCAR) 5MG TAB,1402767,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FIRST-OMEPRAZOLE 2MG/ML SUSP 90ML,1404719,CDM,250,RC,,,outpatient,,,306.27,183.76,,229.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,192.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.75,275.64,
FISH OIL (OMEGA-3) 1000MG CAP,1404071,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FLANDERS BUTTOCKS OINT 120GM,1402148,CDM,250,RC,,,outpatient,,,27.87,16.72,,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.71,25.08,
FLAVOXATE TAB 100MG,1400683,CDM,250,RC,,,outpatient,,,9.56,5.74,,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
FLECAINIDE (TAMBACOR) 100MG TABLET,4783,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FLEXIBLE COLLODION,1401245,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
FLUCONAZOLE (DIFLUCAN) 100MG TAB,1401676,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FLUCONAZOLE (DIFLUCAN) 40MG/ML LIQUID,1402619,CDM,250,RC,,,outpatient,,,459.1,275.46,,344.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,344.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,413.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,344.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,289.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.07,413.19,
FLUDROCORTISONE (FLORINEF) 0.1MG TAB,1400776,CDM,250,RC,,,outpatient,,,4.59,2.75,,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,4.13,
FLUMAZENIL (ROMAZICON) 0.1MG/ML 5ML INJ,1401849,CDM,250,RC,,,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
FLUOCINONIDE CREAM 0.05%,1400948,CDM,250,RC,,,outpatient,,,65.29,39.17,,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.38,58.76,
FLUORESCEIN (BIO GLO) OPHTH STRIPS,1402670,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FLUOXETINE (PROZAC) 10MG CAP,1404724,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FLUOXETINE (PROZAC) 20MG CAP,1401131,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FLUPHENAZINE (PROLIXIN) 2.5MG TAB,1401129,CDM,250,RC,,,outpatient,,,21.31,12.79,,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,19.18,
FLUPHENAZINE DEC(PROLIXIN DEC) 25MG/ML,4702,CDM,250,RC,,,outpatient,,,101.58,60.95,,76.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.81,91.42,
FLUTICASONE PROPIONATE INHALER 110MCG,1402181,CDM,250,RC,,,outpatient,,,461.13,276.68,,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,415.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,290.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.49,415.02,
FLUTICASONE PROPIONATE INHALER 220MCG,1402097,CDM,250,RC,,,outpatient,,,716.29,429.77,,537.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,152.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,537.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,644.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,537.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,451.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.77,644.66,
FLUVOXAMINE (LUVOX) 25MG TABLET,3424,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
FOLIC ACID 1MG TAB,1400231,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FOLIC ACID 5MG/ML INJ 10ML,1401213,CDM,250,RC,J3490,HCPCS,outpatient,,,49.03,29.42,,36.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.05,44.13,
FOSPHENYTOIN (CEREBYX) 50MG/ML 2ML,1402023,CDM,250,RC,Q2009,HCPCS,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
FOSPHENYTOIN SOD.INJ 50MG/ML 10ML,1402024,CDM,250,RC,,,outpatient,,,93.09,55.85,,69.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.07,83.78,
FOSPROPOFOL INJ 35MG/ML,1402757,CDM,250,RC,,,outpatient,,,114.58,68.75,,85.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.48,103.12,
FUROSEMIDE (LASIX) 20MG TAB,1401070,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FUROSEMIDE (LASIX) 40MG TAB,1400329,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
FUROSEMIDE ORAL DROP 60ML 10MG/ML,1400332,CDM,250,RC,,,outpatient,,,3.72,2.23,,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,3.35,
GABAPENTIN (NEURONTIN) 100MG CAP,1402020,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GABAPENTIN (NEURONTIN) 300MG CAP,1402022,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
Gabapentin (NEURONTIN) 400MG CAP,5361,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
Gabapentin (NEURONTIN) 400MG CAP,1404631,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GATIFLOXACIN TAB 400MG,1402141,CDM,250,RC,,,outpatient,,,49.65,29.79,,37.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.17,44.69,
GEMFIBROZIL (LOPID) 600MG TAB,1401684,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GENTAMICIN (GARAMYCIN) OPHTH OINT 0.3%,1400239,CDM,250,RC,,,outpatient,,,17.48,10.49,,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,15.73,
GENTAMICIN (GARAMYCIN) OPHTH SOLN 0.3%,1400309,CDM,250,RC,,,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
GENTAMICIN OINT 0.1%,1400238,CDM,250,RC,,,outpatient,,,20.22,12.13,,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,18.2,
GI COCKTAIL,1401432,CDM,250,RC,,,outpatient,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,6.63,
Glimepiride (AMARYL) 1MG TABLET,1404635,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GLIMEPIRIDE (AMARYL) 4MG TAB,1402072,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GLIPIZIDE (GLUCOTROL) 5MG TAB,1400793,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GLIPIZIDE XL (GLUCOTROL XL) 5MG TAB,1402054,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GLUCOSE (GLUTOSE) 40% 15GM GEL,1402185,CDM,250,RC,,,outpatient,,,18.04,10.82,,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,16.24,
GLYBURIDE (DIABETA) 2.5MG TAB,1400987,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GLYCERIN INFANT SUPP,1401356,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GLYCERIN SUPP (ADULT),1400248,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GLYCOPYRROLATE (ROBINUL) 0.2MG/ML INJ,1400814,CDM,250,RC,,,outpatient,,,10.65,6.39,,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,9.59,
GOLYTELY,1401564,CDM,250,RC,,,outpatient,,,85.79,51.47,,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.58,77.21,
GUAIFENESIN (ROBITUSSIN) 200MG/10ML UD,1402209,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GUAIFENESIN AC (ROB) 200MG/20MG/10ML UD,1404050,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GUAIFENESIN AC 100MG-10MG/5ML,1402484,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
GUAIFENESIN DM (ROBITUSSIN DM)100-10/5ML,1402211,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
GUAIFENESIN ER (MUCINEX) 600MG TAB,1401584,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
GUANABENZ TAB 4MG,1400891,CDM,250,RC,,,outpatient,,,6.9,4.14,,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,6.21,
GUANFACINE TAB 1MG,1401382,CDM,250,RC,,,outpatient,,,5.3,3.18,,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,4.77,
HALOPERIDOL (HALDOL) 1MG TAB,1401066,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HALOPERIDOL (HALDOL) 5MG TAB,1401001,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HALOPERIDOL CONC 2MG/ML,1401250,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
HEPARIN 25000 UN/ 0.45% NS 500ML,1404610,CDM,250,RC,J1644,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,0.32,
HEPARIN LOCK FLUSH 100 UNITS/ML 1ML INJ,1400903,CDM,250,RC,,,outpatient,,,6.56,3.94,,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,5.9,
HEPARIN LOCK FLUSH 100 UNITS/ML 5ML INJ,1404001,CDM,250,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
HEXACHLOROPHENE 3%,1401525,CDM,250,RC,,,outpatient,,,33.42,20.05,,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.85,30.08,
HOMATROPINE OPHTH SOLN. 5%,1401818,CDM,250,RC,,,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,92.44,
HUMALOG INSULIN 75/25,1402142,CDM,250,RC,,,outpatient,,,0.22,0.13,,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.05,0.2,
HYDRALAZINE (APRESOLINE) 10MG TAB,1402763,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDRALAZINE (APRESOLINE) 25MG TAB,1400084,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROCHLOROTHIAZIDE (HCTZ) 25MG TAB,1401063,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROCODONE/ APAP (LORTAB) 7.5-325/15ML,1404637,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
HYDROCODONE/ APAP 7.5MG-325MG/15ML,5036,CDM,250,RC,,,outpatient,,,13.79,8.27,,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,12.41,
HYDROCODONE/APAP (NORCO) 10/325 TAB,1403972,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROCODONE/APAP (NORCO) 5/325 TAB,1402496,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROCODONE/APAP (NORCO) 7.5/325 TAB,1402495,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROCODONE/HOMATROPINE TAB 5MG,1400770,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
HYDROCORTISONE (ANUSOL) 2.5% CR 30GM,1400734,CDM,250,RC,,,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,108.18,
HYDROCORTISONE (CORTISONE) 1% CREAM 28GM,1400809,CDM,250,RC,,,outpatient,,,9.56,5.74,,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
HYDROCORTISONE (HYTONE) 2.5% CREAM 30GM,1401601,CDM,250,RC,,,outpatient,,,56.28,33.77,,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,50.65,
HYDROCORTISONE CREAM 1% (APPL) (ER USE),1402648,CDM,250,RC,,,outpatient,,,6.9,4.14,,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,6.21,
HYDROCORTISONE( ANUSOL HC) 25MG SUPP,1400081,CDM,250,RC,,,outpatient,,,46.99,28.19,,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,42.29,
HYDROGEN PEROXIDE,1400483,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROMORPHONE (DILAUDID) 2MG TAB,1401562,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROXYCHLOROQUINE (PLAQUENIL) 200MG TAB,1402367,CDM,250,RC,,,outpatient,,,6.02,3.61,,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,5.42,
HYDROXYUREA (HYDREA) 500MG CAP,1401811,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROXYZINE HCL (ATARAX) 10MG/5ML LIQ,1400921,CDM,250,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
HYDROXYZINE HCL (ATARAX) 25MG TAB,1400094,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYDROXYZINE PAM (VISTARIL) 25MG CAP,1400707,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYOSCYAMINE (LEVSIN) 0.125MG/5ML ELIXER,1402485,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
HYOSCYAMINE (LEVSIN) 0.125MG/ML DROPS,1400873,CDM,250,RC,,,outpatient,,,78.95,47.37,,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.18,71.06,
HYOSCYAMINE (LEVSIN) 0.125MG/ML ER USE,1402653,CDM,250,RC,,,outpatient,,,5.24,3.14,,3.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,4.72,
HYOSCYAMINE SL (LEVSIN SL) 0.125MG TAB,1401752,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
HYOSCYAMINE SULFATE TAB 0.125MG,1400797,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
IBUPROFEN (MOTRIN) 100MG/5ML SUSP UD,1401913,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
IBUPROFEN (MOTRIN) 600MG TAB,1401099,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
IBUPROFEN (MOTRIN) 800MG TAB,1401100,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
IBUPROFEN (MOTRIN/ADVIL) 200MG TAB,1401016,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
INDIGOTINDISULFONATE SOD. INJ. 0.8% SOLN,1401890,CDM,250,RC,,,outpatient,,,49.07,29.44,,36.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.05,44.16,
INDOCYANINE GREEN 25 MG INJ,1404080,CDM,250,RC,,,outpatient,,,547.69,328.61,,410.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,410.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,410.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,345.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.22,492.92,
INDOMETHACIN CAP 25MG,1400278,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
IPRATROPIUM (ATROVENT) 0.5MG/ 2.5ML NEBS,1401954,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
IPRATROPIUM ORAL SPRAY,1401528,CDM,250,RC,,,outpatient,,,573.14,343.88,,429.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,429.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,515.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,429.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,361.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.44,515.83,
IPRATROPIUM/ALBUTEROL INH,1402070,CDM,250,RC,,,outpatient,,,323.68,194.21,,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,203.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,291.31,
IPRATROPIUM/ALBUTEROL(DUONEB)0.5MG-2.5MG,1404064,CDM,250,RC,J3490,HCPCS,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
IRBESARTAN TAB 150MG,1402093,CDM,250,RC,,,outpatient,,,9.56,5.74,,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
ISOFLURANE 250ML INHAL,1402702,CDM,250,RC,,,outpatient,,,141.23,84.74,,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,127.11,
ISOPROPYL ALCOHOL 70%,1401270,CDM,250,RC,,,outpatient,,,3.55,2.13,,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,3.2,
ISOPROTERENOL 1MG/5ML INJ,1400888,CDM,250,RC,,,outpatient,,,193.96,116.38,,145.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,145.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,122.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.74,174.56,
ISOSORBIDE DINITRATE (ISORDIL) 10MG TAB,1400287,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ISOSORBIDE DINITRATE (ISORDIL) 20MG TAB,1400581,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ISOSORBIDE MONONITRATE (IMDUR) 30MG TAB,1402166,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ISOSORBIDE MONONITRATE (ISMO) 20MG TAB,1401924,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
KETAMINE 500MG INJ,1400306,CDM,250,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
KETOCONAZOLE (NIZORAL) 2% CREAM,1401814,CDM,250,RC,,,outpatient,,,133.67,80.2,,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.39,120.3,
KETOCONAZOLE TAB 200MG,1400979,CDM,250,RC,,,outpatient,,,39.79,23.87,,29.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,35.81,
KETOROLAC (TORADOL) 10MG TAB,1401851,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LABETALOL (TRANDATE) 100MG TAB,1400442,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LABETALOL (TRANDATE) 20MG/4ML INJ,1404722,CDM,250,RC,,,outpatient,,,26.27,15.76,,19.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.38,23.64,
LABETALOL (TRANDATE) 5MG/ML INJ 20ML,1401955,CDM,250,RC,,,outpatient,,,6.02,3.61,,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,5.42,
LABETALOL (TRANDATE) 5MG/ML INJ 40ML,1404721,CDM,250,RC,,,outpatient,,,46.35,27.81,,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,41.72,
LACRI-LUBE OPHTH OINT 7GM,1401313,CDM,250,RC,,,outpatient,,,62.28,37.37,,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.76,56.05,
LACTULOSE 20GM/30ML SOLN UD,1402206,CDM,250,RC,,,outpatient,,,5.19,3.11,,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.67,
LACTULOSE FOR ORAL SOLN 20GMS,1402359,CDM,250,RC,,,outpatient,,,12.73,7.64,,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,11.46,
LAMOTRIGINE (LAMICTAL) 200MG TAB,1402498,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LAMOTRIGINE (LAMICTAL) 25MG,1402101,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LATANOPROST (XALATAN) 0.005% OPHTH SOLN,1402334,CDM,250,RC,,,outpatient,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,24.59,
LEFLUNOMIDE TAB*20MG **,1402406,CDM,250,RC,,,outpatient,,,94.79,56.87,,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,85.31,
LENTE HUMULIN INSULIN,1401363,CDM,250,RC,,,outpatient,,,1.16,0.7,,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,1.04,
LETROZOLE 2.5MG TAB (FEMARA),140001,CDM,250,RC,,,outpatient,,,5.3,3.18,,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,4.77,
LEVALBUTEROL (XOPENEX) 0.63MG/3ML NEBS,1402132,CDM,250,RC,,,outpatient,,,6.02,3.61,,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,5.42,
LEVALBUTEROL (XOPENEX) 1.25MG/3ML NEBS,1402157,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
LEVEMIR 100U/ML INSULIN,1403958,CDM,250,RC,J1815,HCPCS,outpatient,,,1.33,0.8,,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,0.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,1.2,
LEVETIRACETAM (KEPPRA) 500MG TAB,1402488,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LEVOFLOXACIN (LEVAQUIN) 250MG TAB,1404696,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LEVOFLOXACIN (LEVAQUIN) 500MG TAB,1402494,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LEVOFLOXACIN (LEVAQUIN)250MG/50ML PREMIX,1402706,CDM,250,RC,,,outpatient,,,9.56,5.74,,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
LEVOFLOXACIN(LEVAQUIN) 500MG,1402422,CDM,250,RC,,,outpatient,,,57.07,34.24,,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,51.36,
LEVOFLOXACIN(LEVAQUIN)500MG/100ML PREMIX,1402491,CDM,250,RC,J3490,HCPCS,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
LEVOTHYROXINE (SYNTHROID) 100MCG INJ,1403850,CDM,250,RC,J3490,HCPCS,outpatient,,,168.83,101.3,,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,106.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,151.95,
LEVOTHYROXINE (SYNTHROID) 100MCG TAB,1400613,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LEVOTHYROXINE (SYNTHROID) 125MCG TAB,1401886,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LEVOTHYROXINE (SYNTHROID) 200MCG INJ,1401240,CDM,250,RC,,,outpatient,,,216.64,129.98,,162.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,136.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.39,194.98,
LEVOTHYROXINE (SYNTHROID) 25 MCG TAB,1401488,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LEVOTHYROXINE (SYNTHROID) 88MCG TAB,1401693,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LIDOCAINE (LIDODERM) 5% PATCH,1402735,CDM,250,RC,,,outpatient,,,31.15,18.69,,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,28.04,
LIDOCAINE (XYLOCAINE) 0.5% 5MG/ML 50ML,1402232,CDM,250,RC,,,outpatient,,,15.57,9.34,,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,14.01,
LIDOCAINE (XYLOCAINE) 1% 10MG/ML 5ML AMP,1403955,CDM,250,RC,,,outpatient,,,7.59,4.55,,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,6.83,
LIDOCAINE (XYLOCAINE) 1% W/EPI 20ML INJ,1401195,CDM,250,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
LIDOCAINE (XYLOCAINE) 2% 20MG/ML 10ML,1404735,CDM,250,RC,,,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.54,
LIDOCAINE (XYLOCAINE) 2% 20MG/ML 20ML,1402688,CDM,250,RC,,,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.54,
LIDOCAINE (XYLOCAINE) 2% 20MG/ML 30ML,1402639,CDM,250,RC,,,outpatient,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,11.32,
LIDOCAINE (XYLOCAINE) 2% JELLY 30ML,1400724,CDM,250,RC,,,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,132.28,
LIDOCAINE (XYLOCAINE) 2% W/EPI 20ML INJ,1401196,CDM,250,RC,,,outpatient,,,15.85,9.51,,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,14.27,
LIDOCAINE (XYLOCAINE) 2% W/EPI 30ML INJ,1404714,CDM,250,RC,,,outpatient,,,15.85,9.51,,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,14.27,
LIDOCAINE (XYLOCAINE) VISCOUS 2% 15ML UD,1402210,CDM,250,RC,,,outpatient,,,4.92,2.95,,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,4.43,
LIDOCAINE 0.4% 2GM/500ML D5W PREMIX,1400726,CDM,250,RC,,,outpatient,,,35.51,21.31,,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,31.96,
"LIDOCAINE 0.5%/EPINEPHRINE 1:200,000 50",1402179,CDM,250,RC,,,outpatient,,,32.89,19.73,,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,29.6,
LIDOCAINE 1% W/EPI. 10ML (ER USE),1402641,CDM,250,RC,,,outpatient,,,9.82,5.89,,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,8.84,
LIDOCAINE 2% 100MG/5ML ABBJ,1400343,CDM,250,RC,,,outpatient,,,31.15,18.69,,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,28.04,
LIDOCAINE 2% 20MG/ML 20ML,1402036,CDM,250,RC,,,outpatient,,,268.94,161.36,,201.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.11,242.05,
"LIDOCAINE 2%/EPI 1:100,000 10ML INJ",5463,CDM,250,RC,,,outpatient,,,12.28,7.37,,9.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,11.05,
LIDOCAINE INJ 1% INJ 10ML,1402638,CDM,250,RC,,,outpatient,,,5.3,3.18,,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,4.77,
LIDOCAINE INJ 2% 50ML,1401187,CDM,250,RC,,,outpatient,,,33.42,20.05,,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.85,30.08,
LIDOCAINE INJ 4% 50ML,1401910,CDM,250,RC,,,outpatient,,,67.9,40.74,,50.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,61.11,
LIDOCAINE JELLY 2% (APPL.) (ER USE),1402649,CDM,250,RC,,,outpatient,,,18.57,11.14,,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.71,
LIDOCAINE OINT 5%,1400722,CDM,250,RC,,,outpatient,,,47.27,28.36,,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,42.54,
LIDOCAINE UROJET 2% 20MG/ML 10ML JELLY,1402790,CDM,250,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
LIDOCAINE VISCOUS 2%,1400943,CDM,250,RC,,,outpatient,,,7.43,4.46,,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,6.69,
LIDOCAINE VISCOUS 2% (BOTTLE),1400995,CDM,250,RC,,,outpatient,,,12.73,7.64,,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.61,11.46,
LIDOCAINE-MPF (XYLOCAINE) 2% 10ML STPK,1403969,CDM,250,RC,,,outpatient,,,23.88,14.33,,17.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,21.49,
LIDOCAINE-MPF (XYLOCAINE) 2% 5ML INJ,1402174,CDM,250,RC,,,outpatient,,,13.06,7.84,,9.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,11.75,
LIDOCAINE-MPF (XYLOCAINE) 2% INJ 2ML,1404684,CDM,250,RC,,,outpatient,,,9.27,5.56,,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,8.34,
"LIDOCAINE-MPF 1.5% EPI.1:200,000 30ML",1401977,CDM,250,RC,,,outpatient,,,112.55,67.53,,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,101.3,
LIDOCAINE-MPF 1% 30ML AMPULE,1402175,CDM,250,RC,,,outpatient,,,53.31,31.99,,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,47.98,
"LIDOCAINE-MPF 1% EPI:1:200,000 10ML",1402807,CDM,250,RC,,,outpatient,,,36.34,21.8,,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,32.71,
"LIDOCAINE-MPF 1% EPI:1:200,000 30ML",1402758,CDM,250,RC,,,outpatient,,,40.58,24.35,,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,36.52,
"LIDOCAINE-MPF 1% EPI.1:200,000 30ML",1402177,CDM,250,RC,,,outpatient,,,120.75,72.45,,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,108.68,
LIDOCAINE-MPF 2% 10ML POLYAMP DUOFIT UNI,1402180,CDM,250,RC,,,outpatient,,,72.14,43.28,,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,64.93,
"LIDOCAINE-MPF 2% EPI:1:200,000 10ML",1402178,CDM,250,RC,,,outpatient,,,69.75,41.85,,52.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.29,62.78,
LIDOCAINE-MPF 4% 5ML,1402176,CDM,250,RC,,,outpatient,,,40.58,24.35,,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,36.52,
LIDOCAINE-MPF(XYLOCAINE) 1% 10ML STPK,1404703,CDM,250,RC,,,outpatient,,,37.6,22.56,,28.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,33.84,
LIDOCAINE-MPF(XYLOCAINE) 2% 10ML STPK,1401978,CDM,250,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
LIDOCAINE(XYLOCAINE) 1% 2ML INJ VIAL MPF,5519,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
LIDOCAINE/PRILOCAINE (EMLA) 2.5% CR.,1402009,CDM,250,RC,,,outpatient,,,98.9,59.34,,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.26,89.01,
LINDANE LOTION,1403967,CDM,250,RC,,,outpatient,,,767.65,460.59,,575.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,614.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,575.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,690.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,575.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,575.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,575.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,575.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,483.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.29,690.89,
LINDANE SHAMPOO,1400333,CDM,250,RC,,,outpatient,,,471.25,282.75,,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,296.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.56,424.13,
LINEZOLID (ZYVOX) 600MG TAB,1404715,CDM,250,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
LISINOPRIL (ZESTRIL) 10MG TAB,1401493,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LISINOPRIL (ZESTRIL) 5MG TAB,1402430,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LITHIUM CARBONATE 150MG CAP,1404625,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LITHIUM CARBONATE 300MG CAP,1400920,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LITHIUM CARBONATE CAPSULE 150MG,1404611,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LOPERAMIDE (IMODIUM) 2MG CAP,1400281,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LORACARBEF SUSP 100MG/5ML,1401973,CDM,250,RC,,,outpatient,,,67.48,40.49,,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.83,60.73,
LORATADINE (CLARITIN) 10MG TAB,1401994,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LORATADINE (CLARITIN) 5MG/5ML SYRUP,1404044,CDM,250,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
LORAZEPAM (ATIVAN) 0.5MG TAB,1401404,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LORAZEPAM (ATIVAN) 1MG TAB,1400100,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LOSARTAN (COZAAR) 50MG TAB,1401992,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
LOSARTAN HCL/H-THIAZIDE 50-12.5,1402099,CDM,250,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
LOSARTAN TAB 100MG,1402479,CDM,250,RC,,,outpatient,,,9.65,5.79,,7.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,8.69,
LUBRIDERM LOT,1400976,CDM,250,RC,,,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,25.33,
M,5499,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MAGIC MOUTHWASH,1403994,CDM,250,RC,,,outpatient,,,3,1.8,,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,2.7,
MAGNESIUM CHLORIDE TAB 64MG,1401826,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
MAGNESIUM CITRATE (CITROMA) 300ML,1400375,CDM,250,RC,,,outpatient,,,7.65,4.59,,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,6.89,
MAGNESIUM OXIDE 250MG TAB,1401557,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MAGNESIUM SULF. 4GM/100ML,1402202,CDM,250,RC,,,outpatient,,,30.66,18.4,,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,27.59,
MAGNESIUM/ALUM/SIMETH (MAALOX PLUS) 30ML,1402235,CDM,250,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
MAGNESIUM/ALUMINUM HYDROXIDE SUSP,1400367,CDM,250,RC,,,outpatient,,,2.12,1.27,,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,1.91,
MAGNESIUM/ALUMINUM HYDROXIDE SUSP 5OZ.,1401530,CDM,250,RC,,,outpatient,,,4.99,2.99,,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,4.49,
MECLIZINE (ANTIVERT) 12.5MG TAB,1400078,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MEDLINE MOISTURE BARRIER CREAM,2103417,CDM,250,RC,,,outpatient,,,36.87,22.12,,27.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.55,33.18,
MEDLINE POWDER,2112569,CDM,250,RC,,,outpatient,,,10.11,6.07,,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,9.1,
MEDROL DOSEPAK,1402577,CDM,250,RC,,,outpatient,,,87.42,52.45,,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,78.68,
MEDROXYPROGESTERONE (PROVERA) 5MG TAB,4837,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MEGESTROL (MEGACE) 400MG/10ML UD CUP,1402051,CDM,250,RC,,,outpatient,,,13.11,7.87,,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,11.8,
MEGESTROL (MEGACE) 40MG TAB,1401535,CDM,250,RC,,,outpatient,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,6.15,
MELATONIN 3MG TABLET,1474718,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MELOXICAM (MOBIC) 15MG TAB,1402774,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MEMANTINE (NAMENDA) 10MG TAB,1402602,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MEPERIDINE (DEMEROL) 50MG/ML 2ML INJ,1404613,CDM,250,RC,,,outpatient,,,10.11,6.07,,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,9.1,
MEPERIDINE TAB 50MG,1400162,CDM,250,RC,,,outpatient,,,6.63,3.98,,4.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,5.97,
MEPIVACAINE 1.5% 30ML,1402713,CDM,250,RC,,,outpatient,,,22.81,13.69,,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.53,
MEPROBAMATE 200MG,1402466,CDM,250,RC,,,outpatient,,,5.2,3.12,,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,4.68,
MEROPENEM IV PWD FOR SOLN 1GM,1404595,CDM,250,RC,,,outpatient,,,119.39,71.63,,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,107.45,
MESALAMINE*TAB 400MG,1402261,CDM,250,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
METAPROTERENOL INHALATION SOLN. 0.6%,1401785,CDM,250,RC,,,outpatient,,,6.79,4.07,,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,6.11,
METAXALONE (SKELAXIN) 800MG TAB,1402395,CDM,250,RC,,,outpatient,,,16.97,10.18,,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,15.27,
METAXALONE 400MG,1401916,CDM,250,RC,,,outpatient,,,6.05,3.63,,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,5.45,
METFORMIN (GLUCOPHAGE) 500MG TAB,1401995,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METFORMIN (GLUCOPHAGE) 850MG TAB,1404733,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METHADONE (DOLOPHINE) 10MG TAB,1401985,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METHIMAZOLE ORAL TABLET 5MG,1404693,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
METHOCARBAMOL (ROBAXIN) 500MG TAB,1401133,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METHOTREXATE*2.5MG**,1402264,CDM,250,RC,,,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,25.82,
METHYLCELLOSE OPTH DROPS,1400808,CDM,250,RC,,,outpatient,,,56.76,34.06,,42.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.63,51.08,
METHYLCELLULOSE (CITRUCEL) 500MG TAB,1401534,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METHYLDOPA (ALDOMET) 250MG TAB,1400042,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METHYLERGONOVINE TAB 0.2MG,1400750,CDM,250,RC,,,outpatient,,,4.14,2.48,,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,3.73,
METHYLPHENIDATE (RITALIN) 5MG TAB,1401480,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METHYLPREDNISOLONE (MEDROL) 4MG TAB,1401762,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METOCLOPRAMIDE (REGLAN) 5MG TAB,1401549,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METOCLOPRAMIDE (REGLAN)10MG/10ML SOLN UD,1402208,CDM,250,RC,,,outpatient,,,6.02,3.61,,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,5.42,
METOLAZONE (ZAROXOLYN) 2.5MG TAB,1400855,CDM,250,RC,,,outpatient,,,9.56,5.74,,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
METOPROLOL (LOPRESSOR) 1MG/ML INJ 5ML,1401771,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METOPROLOL SUCC XL (TOPROL XL) 25MG TAB,1402441,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METOPROLOL SUCC XL (TOPROL XL) 50MG TAB,1402167,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
METOPROLOL SUCC. XL 100MG,1402168,CDM,250,RC,,,outpatient,,,5.94,3.56,,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,5.35,
METOPROLOL TART (LOPRESSOR) 50MG TAB,1400352,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METRONIDAZOLE (FLAGYL) 250MG TAB,1400748,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
METRONIDAZOLE (FLAGYL) 500MG/100ML PM,1400893,CDM,250,RC,,,outpatient,,,9.29,5.57,,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,8.36,
METRONIDAZOLE (METROGEL) 0.75% VAG GEL,1401950,CDM,250,RC,,,outpatient,,,317.7,190.62,,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,200.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.1,285.93,
METRONIDAZOLE TAB 500MG,1401570,CDM,250,RC,,,outpatient,,,5.2,3.12,,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,4.68,
MEXILETINE CAP 200MG,1401081,CDM,250,RC,,,outpatient,,,3.72,2.23,,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,3.35,
MICONAZOLE (MONISTAT 7)2% VAGINAL CR 45G,1400385,CDM,250,RC,,,outpatient,,,66.12,39.67,,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,59.51,
MICONAZOLE-3 VAG. SUPP,1401514,CDM,250,RC,,,outpatient,,,120.48,72.29,,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,108.43,
MICONAZOLE-7 VAG. SUPP,1401600,CDM,250,RC,,,outpatient,,,55.73,33.44,,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,50.16,
MIDODRINE (PROAMATINE) 5MG TAB,3886,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MIDODRINE (PROAMATINE) 5MG TAB,1404669,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
MIDRIN CAP,1402449,CDM,250,RC,,,outpatient,,,2.02,1.21,,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,1.82,
MILK OF MAGNESIA 30ML UD,1400398,CDM,250,RC,,,outpatient,,,7.92,4.75,,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,7.13,
MINERAL OIL 30ML,1400773,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MINERAL OIL LIGHT 10ML,1402600,CDM,250,RC,,,outpatient,,,110.92,66.55,,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,99.83,
MINOXIDIL (LONITEN) 2.5MG TAB,1400857,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MIRTAZAPINE (REMERON) 15MG ODT TAB,1402081,CDM,250,RC,,,outpatient,,,6.33,3.8,,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,5.7,
MISOPROSTOL (CYTOTEC) 100MCG TAB,1404589,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
MIVACURIUM INJ 2MG/ML,1401853,CDM,250,RC,,,outpatient,,,146.4,87.84,,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,131.76,
MODAFINIL TAB 100MG,1402231,CDM,250,RC,,,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,25.33,
MOEXIPRIL HCL 7.5MG,1402052,CDM,250,RC,,,outpatient,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.17,
MOMETASONE FUROATE*NASAL*SPRAY **,1402398,CDM,250,RC,,,outpatient,,,251.43,150.86,,188.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.52,226.29,
MONTELUKAST (SINGULAIR) 10MG TAB,1402069,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MORPHINE 20MG/ML SOLN 30ML,1404081,CDM,250,RC,,,outpatient,,,23.23,13.94,,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.91,
MORPHINE 8MG/1ML INJ,1401448,CDM,250,RC,J2270,HCPCS,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,7.62,
MORPHINE ER (MS CONTIN) 15MG TAB,1401800,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
MORPHINE I.R TAB. 15MG,1402194,CDM,250,RC,,,outpatient,,,3,1.8,,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,2.7,
MORPHINE SO4 15MG/ML 20ML,1401645,CDM,250,RC,,,outpatient,,,18.04,10.82,,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.7,16.24,
MORPHINE SULFATE ORAL SOLN. 10MG/5ML,1401460,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
MOXIFLOXACIN (VIGAMOX) 0.5% OPH SOLN 3ML,1402229,CDM,250,RC,,,outpatient,,,265.53,159.32,,199.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,199.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,167.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.41,238.98,
MUCOLYTIC PER ML.,2600048,CDM,250,RC,,,outpatient,,,7.64,4.58,,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,6.88,
MULTIHANCE (GADOBENATE) 529MG/ML 15ml,1404705,CDM,250,RC,,,outpatient,,,132.61,79.57,,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.17,119.35,
MULTIHANCE (GADOBENATE) 529MG/ML 20ML,1404605,CDM,250,RC,,,outpatient,,,178.12,106.87,,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,112.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,160.31,
MULTITRACE-5 INJECTION,1404061,CDM,250,RC,,,outpatient,,,30.6,18.36,,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,27.54,
MUMPS SKIN TEST ANTIGEN,1401652,CDM,250,RC,,,outpatient,,,53.27,31.96,,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,47.94,
MUPIROCIN (BACTROBAN) 2% OINT 1GM UD,1404720,CDM,250,RC,,,outpatient,,,13.91,8.35,,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.52,
MUPIROCIN (BACTROBAN) 2% OINT 22GM,1401322,CDM,250,RC,,,outpatient,,,56.83,34.1,,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,51.15,
MVI-12 (INFUVITE) 10ML INJ,1400780,CDM,250,RC,,,outpatient,,,41.52,24.91,,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,37.37,
NADOLOL (CORGARD) 20MG TABLET,1404679,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
NAFCILLIN :500MG INJ,1400751,CDM,250,RC,,,outpatient,,,53.05,31.83,,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,47.75,
NAFCILLIN 1GM VIAL,1400752,CDM,250,RC,,,outpatient,,,21.58,12.95,,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,19.42,
NAFCILLIN: 2000MG INJ,1402681,CDM,250,RC,S0032,HCPCS,outpatient,,,71.62,42.97,,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,26.73,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,45.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,64.46,
NALTREXONE TAB 50MG,1401894,CDM,250,RC,,,outpatient,,,19.63,11.78,,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,17.67,
NEBIVOLOL (BYSTOLIC) 5MG TABLET,4228,CDM,250,RC,,,outpatient,,,20.76,12.46,,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,18.68,
NEDOCROMIL SODIUM INH.,1402033,CDM,250,RC,,,outpatient,,,174.52,104.71,,130.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.76,157.07,
NEFAZODONE TAB 100MG,1402067,CDM,250,RC,,,outpatient,,,8.91,5.35,,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,8.02,
NEO/BAC/POLY (NEOSPORIN) OINTMENT PACKET,1400992,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NEO/POLY/BACI(NEOSPORIN) OPHTH OINT 3.5G,1400440,CDM,250,RC,,,outpatient,,,94.96,56.98,,71.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.46,85.46,
NEO/POLY/DEX (MAXITROL) OPHTH OINT 3.5GM,1402777,CDM,250,RC,,,outpatient,,,85.93,51.56,,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.61,77.34,
NEOMYCIN 500MG,1400434,CDM,250,RC,,,outpatient,,,8.49,5.09,,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.64,
NEOMYCIN/DEXAMETHASONE OPHTH SOLN 0.1%,1400429,CDM,250,RC,,,outpatient,,,110.09,66.05,,82.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.56,99.08,
NEOMYCIN/FLUOCINOLONE CREAM 0.025%,1400443,CDM,250,RC,,,outpatient,,,42.54,25.52,,31.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.72,38.29,
NEOMYCIN/POLY/BAC/HC OPHTH OINTMENT,1401301,CDM,250,RC,,,outpatient,,,123.6,74.16,,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,111.24,
NEOSPORIN G.U. IRRIGANT,1400252,CDM,250,RC,,,outpatient,,,70.48,42.29,,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,63.43,
NEOSPORIN OPHTH SOLN,1400441,CDM,250,RC,,,outpatient,,,108.18,64.91,,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,68.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,97.36,
NF- FEBUXOSTAT (Uloric) 40MG TAB,4303,CDM,250,RC,,,outpatient,,,46.71,28.03,,35.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.57,42.04,
NF-ACEBUTOLOL (SECTRAL) 200MG CAP,4415,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-ANAPROX 275MG TAB,1400969,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
NF-Armour Thyroid Tablet 60MG,4696,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-AUGMENTIN SUSP 125MG/5ML,1400895,CDM,250,RC,,,outpatient,,,92.61,55.57,,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.98,83.35,
NF-BENAZEPRIL TAB 10MG,1401786,CDM,250,RC,,,outpatient,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,6.15,
NF-BETAMETHASONE OINT 15GM,1401321,CDM,250,RC,,,outpatient,,,35.51,21.31,,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,31.96,
NF-BETAMETHASONE VALERATE LOT 0.1%,1401686,CDM,250,RC,,,outpatient,,,63.38,38.03,,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,57.04,
NF-BUPROPION TAB 100MG,1401587,CDM,250,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
NF-BUSPIRONE (BUSPAR) 10MG TAB,1404604,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-BUSPIRONE (BUSPAR) 7.5MG TAB,1404606,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-BUTALBITAL/ACETAMINOPHEN/CAFFEINE TAB,1401110,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
NF-Bystolic Oral Tablet 10MG,3026,CDM,250,RC,,,outpatient,,,19.06,11.44,,14.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,17.15,
NF-CAPTOPRIL TAB 12.5MG,1401384,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
NF-CARBAMAZEPAM XR (TEGRETOL) 200MG TAB,5357,CDM,250,RC,,,outpatient,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,10.82,
NF-CEFACLOR CAP 250MG,1400811,CDM,250,RC,,,outpatient,,,11.21,6.73,,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,10.09,
NF-CEFACLOR SUSP 125MG/5ML,1400813,CDM,250,RC,,,outpatient,,,68.3,40.98,,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,61.47,
NF-CEFACLOR SUSP 125MG/5ML (1ML) ER ONLY,1402631,CDM,250,RC,,,outpatient,,,1.6,0.96,,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.33,1.44,
NF-CHLORDIAZEPOXIDE CAP 25MG,1401093,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
NF-CLARITHROMYCIN SUSP 250MG/5ML,1401997,CDM,250,RC,,,outpatient,,,384.37,230.62,,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,242.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.76,345.93,
NF-CLARITHROMYCIN TAB 250MG,1401937,CDM,250,RC,,,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,25.82,
NF-CLOTRIMAZOLE 1% VAGINAL CREAM,1401461,CDM,250,RC,,,outpatient,,,65.51,39.31,,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.42,58.96,
NF-cloZAPine Oral Tablet 50MG,5489,CDM,250,RC,,,outpatient,,,5.77,3.46,,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.19,
NF-DIPHENHYDRAMINE INJ 50MG,1401589,CDM,250,RC,,,outpatient,,,35.97,21.58,,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,32.37,
NF-Emtricitabine Oral Cap 200MG,6380,CDM,250,RC,,,outpatient,,,71.84,43.1,,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.72,64.66,
NF-ENALAPRIL MALEATE TAB 20MG,1402004,CDM,250,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
NF-ENALAPRIL MALEATE TAB 5MG,1400691,CDM,250,RC,,,outpatient,,,6.56,3.94,,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,5.9,
NF-ENALAPRIL/H-THIAZIDE TAB 10/25,1401174,CDM,250,RC,,,outpatient,,,7.43,4.46,,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,6.69,
NF-ESZOPICLONE TAB 1MG,1402489,CDM,250,RC,,,outpatient,,,20.76,12.46,,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,18.68,
NF-EX-LAX CAPLETS,1401047,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
NF-FAMOTIDINE (PEPCID) 10MG TABLET,5534,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-FEXOFENADINE 180MG TAB,1402258,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-FEXOFENADINE*60MG/PSEUDOEPHED 120MG,1402311,CDM,250,RC,,,outpatient,,,11.47,6.88,,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,10.32,
NF-First-Omeprazole Pwd for Susp 2MG/1ML,6349,CDM,250,RC,,,outpatient,,,257.5,154.5,,193.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,193.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,193.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,162.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,231.75,
NF-FLUNISOLIDE NASAL SPRAY 0.025%,1401299,CDM,250,RC,,,outpatient,,,224.28,134.57,,168.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,168.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.95,201.85,
NF-FOSINOPRIL 10MG,1401861,CDM,250,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
NF-Glimepiride (AMARYL) Oral Tablet 1MG,5631,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
NF-Glycopyrrolate Oral Tablet 1MG,5591,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
NF-HYDROCORTISONE CREAM 0.5%,1401333,CDM,250,RC,,,outpatient,,,12.3,7.38,,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,11.07,
NF-HYDROCORTISONE LOTION 0.5%,1400056,CDM,250,RC,,,outpatient,,,42.08,25.25,,31.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.62,37.87,
NF-HYDROCORTISONE LOTION 1%,1401331,CDM,250,RC,,,outpatient,,,62.56,37.54,,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.82,56.3,
NF-HYDROCORTISONE LOTION 2.5%,1401330,CDM,250,RC,,,outpatient,,,77.58,46.55,,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.9,69.82,
NF-IsoniaziD 100MG TAB,5384,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-ISONIAZID 300MG TABLET,4296,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-LANSOPRAZOLE 15MG CAP,1402061,CDM,250,RC,,,outpatient,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,24.1,
NF-LANSOPRAZOLE 30MG CAP.,1402147,CDM,250,RC,,,outpatient,,,24.04,14.42,,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,21.64,
NF-LANSOPRAZOLE SOLU-TAB 15MG,1402678,CDM,250,RC,,,outpatient,,,19.39,11.63,,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,17.45,
NF-LANSOPRAZOLE SOLU-TAB 30MG,1402463,CDM,250,RC,,,outpatient,,,19.39,11.63,,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,17.45,
NF-LEVOFLOXACIN TAB 250MG,1402805,CDM,250,RC,,,outpatient,,,56.55,33.93,,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,50.9,
NF-LEVOTHYROXINE (SYNTHROID) 150MCG TAB,1401170,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-LIOTHYRONINE (CYTOMEL) 25MCG TAB,4967,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-MEDROXYPROGESTERONE (PROVERA) 10MG,4439,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-MEDROXYPROGESTERONE(PROVERA) 5MG TAB,1402125,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-Mesalamine Cap ER 0.375GM,5699,CDM,250,RC,,,outpatient,,,15.91,9.55,,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,14.32,
NF-METFORMIN*EXTENEDE RELEASE 500MG **,1402248,CDM,250,RC,,,outpatient,,,6.56,3.94,,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,5.9,
NF-Methenamine Hippurate 1GM Tablet,5700,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-METHOCARBAMOL TAB 750MG,1400534,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
NF-METHYLPREDNISOLONE*TAB 4MG DOSEPAK**,1402302,CDM,250,RC,,,outpatient,,,86.05,51.63,,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,77.45,
NF-METOCLOPRAMIDE TAB 10MG,1404587,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
NF-MEXILETINE CAP 150MG,1401082,CDM,250,RC,,,outpatient,,,6.9,4.14,,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,6.21,
NF-MIDODRINE (PROAMATINE) 10MG TAB,4883,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-Minocycline 100MG CAP,4895,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-MOMETASONE (NASONEX) 50MCG/SPRAY NS,1402585,CDM,250,RC,,,outpatient,,,365.25,219.15,,273.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,273.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,328.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,230.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.84,328.73,
NF-Naltrexone (VIVATROL) 50MG TABLET,5716,CDM,250,RC,,,outpatient,,,8.2,4.92,,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,7.38,
NF-NAPROXEN (ALEVE) 220MG TAB,5829,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-NATEGLINIDE TAB 120MG,1402371,CDM,250,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
NF-NEOSPORIN TOP. OINT,1400439,CDM,250,RC,,,outpatient,,,21.03,12.62,,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,18.93,
NF-NITROGLYCERIN 0.1MG/HR PATCH,1402360,CDM,250,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
NF-NITROGLYCERIN OINT (TUBE),1403978,CDM,250,RC,,,outpatient,,,226.2,135.72,,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,203.58,
NF-NIZATIDINE CAP 150MG,1401007,CDM,250,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
NF-OLMESARTAN MEDOXOMIL 20MG TAB,1402771,CDM,250,RC,,,outpatient,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,10.82,
NF-OMEPRAZOLE (PRILOSEC) 20MG CAP,1402440,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-OMEPRAZOLE 2MG/MLSUSPENSION,1404065,CDM,250,RC,,,outpatient,,,121.29,72.77,,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,109.16,
NF-ORPHENADRINE TAB 100MG,1400453,CDM,250,RC,,,outpatient,,,12.3,7.38,,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,11.07,
NF-OXAZEPAM CAP 10MG,1401138,CDM,250,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
NF-OXAZEPAM CAP 15MG,1400556,CDM,250,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
NF-PERPHENAZINE 2MG TABLET,1401385,CDM,250,RC,,,outpatient,,,5.19,3.11,,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.67,
NF-PIROXICAM CAP 20MG,1400931,CDM,250,RC,,,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
NF-Prazosin (MINIPRES) 2MG CAP,5679,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-PREDNISOLONE (PEDIAPRED)6.7MG/5ML SOL,1402164,CDM,250,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
NF-PROPYLTHIOURACIL 50MG TAB,1400928,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
NF-PROzac Capsule 10MG,5398,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-PYRAZINAMIDE 500MG,1401915,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
NF-QUINAPRIL (ACCUPRIL) 10MG TAB,1402184,CDM,250,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
NF-RAMIPRIL 2.5MG CAP,1401778,CDM,250,RC,,,outpatient,,,8.2,4.92,,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,7.38,
NF-RANITIDINE (ZANTAC) 150MG TAB,1400964,CDM,250,RC,,,outpatient,,,8.2,4.92,,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,7.38,
NF-ROPINIROLE 3MG TAB (REQUIP),1402613,CDM,250,RC,,,outpatient,,,35.51,21.31,,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,31.96,
NF-SECTRAL (ACEBUTOLOL)CAP 200MG,1401532,CDM,250,RC,,,outpatient,,,6.56,3.94,,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,5.9,
NF-SERTRALINE TAB. 100MG,1401877,CDM,250,RC,,,outpatient,,,15.65,9.39,,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,14.09,
NF-SIMVASTATIN (ZOCOR) 10MG TAB,1402053,CDM,250,RC,,,outpatient,,,14.58,8.75,,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,13.12,
NF-SIMVASTATIN (ZOCOR) 40MG TAB,1402268,CDM,250,RC,,,outpatient,,,7.92,4.75,,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,7.13,
NF-SOD POLYSTYRENE W/O SORBITOL15GM/60ML,1402669,CDM,250,RC,,,outpatient,,,48.64,29.18,,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.97,43.78,
NF-STROMECTOL TABLET 3MG,1404073,CDM,250,RC,,,outpatient,,,20.49,12.29,,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,18.44,
NF-TEGASEROD MALEATE 6MG,1402282,CDM,250,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
NF-TEKTURNA TAB 150MG,1402762,CDM,250,RC,,,outpatient,,,13.11,7.87,,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,11.8,
NF-Telmisartan (MICARDIS) 40MG TAB,3781,CDM,250,RC,,,outpatient,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,15.25,
NF-TELMISARTAN 40MG TAB,1402490,CDM,250,RC,,,outpatient,,,9.82,5.89,,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,8.84,
NF-TERAZOSIN CAP 1MG,1401663,CDM,250,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
NF-TERAZOSIN CAP 5MG,1401983,CDM,250,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
NF-TERCONAZOLE VAG.SUPP,1400990,CDM,250,RC,,,outpatient,,,122.66,73.6,,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.13,110.39,
NF-TETRACYCLINE CAP 250MG,1400634,CDM,250,RC,,,outpatient,,,7.92,4.75,,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,7.13,
NF-TICAGRELOR (BRILINTA) 60MG TAB,5405,CDM,250,RC,,,outpatient,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,24.59,
NF-TIMOLOL MALEATE OPHTH SOLN 0.5%,5008,CDM,250,RC,,,outpatient,,,30.77,18.46,,23.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.3,27.69,
NF-Timolol Maleate Ophth Solution 0.5%,5659,CDM,250,RC,,,outpatient,,,31.69,19.01,,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,28.52,
NF-TIOTROPIUM BROM.INH SOLN HANDIHALER,1402480,CDM,250,RC,,,outpatient,,,152.99,91.79,,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,137.69,
NF-TIOTROPIUM BROMIDE 18MCG,1402697,CDM,250,RC,,,outpatient,,,150.52,90.31,,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,135.47,
NF-TOLTERODINE TARTRATE 2MG,1402094,CDM,250,RC,,,outpatient,,,15.3,9.18,,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,13.77,
NF-VERAPAMIL S.R. CAPLET 180MG,1401702,CDM,250,RC,,,outpatient,,,7.65,4.59,,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,6.89,
NF-VIOKASE TAB,1400953,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
NF-ZINC OXIDE OINT. 1 LB**,1402587,CDM,250,RC,,,outpatient,,,50.54,30.32,,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.36,45.49,
NF-ZONISAMIDE (ZONAGEN) 100MG CAP,5799,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NF-ZOVIRAX CREAM,1400942,CDM,250,RC,,,outpatient,,,1057.76,634.66,,793.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,793.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,951.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,793.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,793.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,793.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,793.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,666.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.74,951.98,
NIACIN ER (NIASPAN) 250MG CAP,1400445,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NICARDIPINE (CARDENE) 2.5MG/ML 10ML INJ,5550,CDM,250,RC,,,outpatient,,,99.99,59.99,,74.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.49,89.99,
NICARDIPINE (CARDENE) 20MG CAP,1404047,CDM,250,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
NICOTINE (NICODERM) 14MG PATCH,1401967,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
NICOTINE (NICODERM) 21MG PATCH,1402676,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
NICOTINE (NICODERM) 7MG PATCH,1401966,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
NIFEDIPINE (PROCARDIA) 10MG CAP,1400904,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
NIFEDIPINE XL (PROCARDIA XL) 30MG TAB,1401593,CDM,250,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
NITROFURANTOIN (MACRODANTIN) 50MG CAP,1400362,CDM,250,RC,,,outpatient,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,6.63,
NITROGLYCERIN (NITRO-BID) 2% OINT 1G PKT,1401475,CDM,250,RC,,,outpatient,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.17,
NITROGLYCERIN (NITRO-DUR) 0.2MG/HR PATCH,1400966,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NITROGLYCERIN (NITRO-DUR) 0.4MG/HR PATCH,1401295,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
NITROGLYCERIN (NITROSTAT) SL 0.4MG TAB,1400448,CDM,250,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
NITROGLYCERIN 25MG/250ML D5W BOTTLE,1401605,CDM,250,RC,,,outpatient,,,72.12,43.27,,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,64.91,
NITROGLYCERIN INJ 50MG/10ML,1400950,CDM,250,RC,,,outpatient,,,38.19,22.91,,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,34.37,
NITROGLYCERIN LINGUAL AEROSOL,1401801,CDM,250,RC,,,outpatient,,,495.01,297.01,,371.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,371.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,371.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,311.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.43,445.51,
NITROGLYCERIN OINT,1400449,CDM,250,RC,,,outpatient,,,30.13,18.08,,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,27.12,
NITROGLYCERIN PATCH 0.6MG/HR,1401296,CDM,250,RC,,,outpatient,,,7.85,4.71,,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,7.07,
NITROGLYCERIN SL 0.4MG (EACH) FOR ER,1402629,CDM,250,RC,,,outpatient,,,2.46,1.48,,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,2.21,
NITROPRUSSIDE (NIPRIDE) 25MG/ML 2ML INJ,1404659,CDM,250,RC,,,outpatient,,,531.88,319.13,,398.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,398.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,478.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,398.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,335.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.98,478.69,
NOREPINEPH(LEVO)8MG/500ML D5W(16MCG/ML),1404016,CDM,250,RC,,,outpatient,,,92.06,55.24,,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,82.85,
NOREPINEPHRINE (LEVOPHED) 1MG/ML INJ 4ML,1400334,CDM,250,RC,J3490,HCPCS,outpatient,,,88.46,53.08,,66.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.13,79.61,
NORTRIPTYLINE CAP 10MG,1401477,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
NORTRIPTYLINE CAP 25MG,1401118,CDM,250,RC,,,outpatient,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.17,
NOT TO BE USED,1402226,CDM,250,RC,,,outpatient,,,9.82,5.89,,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,8.84,
NOVOLIN N (INSULIN) 100U/ML,1401361,CDM,250,RC,J1815,HCPCS,outpatient,,,1.09,0.65,,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,0.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,0.98,
NOVOLOG (INSULIN) 100U/ML,1402076,CDM,250,RC,J1815,HCPCS,outpatient,,,1.09,0.65,,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,0.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,0.98,
NOVOLOG MIX (INSULIN) 70/30 100U/ML,1402492,CDM,250,RC,J1815,HCPCS,outpatient,,,1.09,0.65,,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,0.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,0.98,
NUPERCAINAL OINT.,1400438,CDM,250,RC,,,outpatient,,,15.57,9.34,,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,14.01,
"NYSTATIN (MYCOSTATIN) 500,000UN/5ML UD",1464639,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
"NYSTATIN (NYSTOP)100,000 UN/GM TOP PWD",1400396,CDM,250,RC,,,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,39.83,
"NYSTATIN 100,000 UNITS/ML (1ML) ER ONLY",1402630,CDM,250,RC,,,outpatient,,,2.39,1.43,,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,2.15,
"NYSTATIN 100,000 UNITS/ML (60ml bottle)",1400393,CDM,250,RC,,,outpatient,,,57.02,34.21,,42.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.68,51.32,
"NYSTATIN 500,000 UNITS",5530,CDM,250,RC,,,outpatient,,,6.41,3.85,,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,5.77,
"NYSTATIN OINT 100,000 UNITS/GM",1400395,CDM,250,RC,,,outpatient,,,15.3,9.18,,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,13.77,
"NYSTATIN(MYCOSTATIN)100,000 UN/GM CR 15G",1402604,CDM,250,RC,,,outpatient,,,39.89,23.93,,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,35.9,
NYSTATIN/TRIAMCIN (MYCOLOG) CREAM 15GM,1400391,CDM,250,RC,,,outpatient,,,83.33,50,,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,75,
NYSTATIN/TRIAMCIN (MYCOLOG) CREAM 60GM,5658,CDM,250,RC,,,outpatient,,,216.36,129.82,,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,136.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.33,194.72,
OCTREOTIDE (SANDOSTATIN) 0.1MG/ML INJ,1404707,CDM,250,RC,,,outpatient,,,26.52,15.91,,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,23.87,
OCUVITE,1401949,CDM,250,RC,,,outpatient,,,3.72,2.23,,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,3.35,
OFLOXACIN OPHTH. SOLN. 0.3%,1402117,CDM,250,RC,,,outpatient,,,225.92,135.55,,169.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.29,203.33,
OFLOXACIN TAB 200MG,1401859,CDM,250,RC,,,outpatient,,,40.85,24.51,,30.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.37,36.77,
OLANZAPINE (ZYPREXA ZYDIS) 5MG ODT TAB,1402021,CDM,250,RC,,,outpatient,,,9.29,5.57,,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,8.36,
ONDANSETRON (ZOFRAN) 4MG ODT TAB,1402305,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
OPIUM TINCTURE 2%,1404043,CDM,250,RC,,,outpatient,,,15.65,9.39,,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,14.09,
ORAJEL 20%,1401553,CDM,250,RC,,,outpatient,,,20.49,12.29,,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.2,18.44,
OSELTAMIVIR (TAMIFLU) 6MG/ML SUSP ER 1ML,1404588,CDM,250,RC,,,outpatient,,,9.82,5.89,,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,8.84,
OSELTAMIVIR (TAMIFLU) 75MG CAPSULE,1402364,CDM,250,RC,,,outpatient,,,13.67,8.2,,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,12.3,
OSELTAMIVIR (TAMIFLU)6MG/ML SUSP 60ML,1402473,CDM,250,RC,,,outpatient,,,302.63,181.58,,226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,190.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.01,272.37,
OXCARBAZEPINE (TRILEPTAL) 150MG TAB,1404713,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
OXCARBAZEPINE (TRILEPTAL) 300MG TAB,1404590,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
OXYBUTYNIN (DITROPAN) 5MG TAB,1400022,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
OXYCODONE ER (OXYCONTIN) 10MG TAB,1402005,CDM,250,RC,,,outpatient,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,13.03,
OXYCODONE HCL C.R. 40MG,1402450,CDM,250,RC,,,outpatient,,,28.64,17.18,,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,25.78,
OXYCODONE IR (OXY IR) 10MG TAB,1403970,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
OXYCODONE IR (OXY IR) 5MG TAB,1402756,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
OXYCODONE/APAP (PERCOCET) 5/325 TAB,1400767,CDM,250,RC,,,outpatient,,,1.09,0.65,,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,0.98,
OXYMETAZOLINE (AFRIN) NASAL SPRAY,1400038,CDM,250,RC,,,outpatient,,,26.22,15.73,,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,23.6,
PAMIDRONATE 90MG/NS 250ML,1404711,CDM,250,RC,J2430,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.58,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,13.34,
PANTOPRAZOLE (PROTONIX) 40MG TAB,1403976,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PANTOPRAZOLE 40MG,1402151,CDM,250,RC,,,outpatient,,,17.51,10.51,,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,15.76,
PAROXETINE (PAXIL) 20MG TAB,1401917,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PENICILLIN VK SUSP 125MG/5ML,1400701,CDM,250,RC,,,outpatient,,,33.33,20,,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,30,
PENICILLIN VK TAB 250MG,1400703,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
PENTAZOCINE/ACETAMINOPHEN TAB,1400985,CDM,250,RC,,,outpatient,,,6.1,3.66,,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,5.49,
PENTAZOCINE/NALOXONE TAB 50MG,1400619,CDM,250,RC,,,outpatient,,,6.1,3.66,,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,5.49,
PENTOXIFYLLINE ER (TRENTAL) 400MG TAB,1401152,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PERFOROMIST INHALATION SOLN 20MCG/2ML,1404079,CDM,250,RC,,,outpatient,,,29.23,17.54,,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,26.31,
PERMETHRIN (ELIMITE) 5% CREAM 60GM,1404029,CDM,250,RC,,,outpatient,,,201.61,120.97,,151.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.31,181.45,
PERMETHRIN (NIX) CREME RINSE,1404695,CDM,250,RC,,,outpatient,,,45.09,27.05,,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.24,40.58,
PERPHENAZINE (TRILAFON) 4MG TAB,1404085,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PETROLATUM (VASELINE) JELLY,1400945,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PHENAZOPYRIDINE (PYRIDIUM) 100MG TAB,1400521,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PHENOBARBITAL 64.8MG (1 gr) TAB,1401396,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PHENOBARBITAL ELIXIR 20MG/5ML,1400756,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PHENOBARBITAL TAB 16.2MG,1401395,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PHENOL (CHLORASEPTIC) 1.4% SPRAY,1400155,CDM,250,RC,,,outpatient,,,9.12,5.47,,6.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,8.21,
PHENTOLAMINE (REGITINE) 5MG/2ML INJ,1404620,CDM,250,RC,,,outpatient,,,898.22,538.93,,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,808.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,565.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.05,808.4,
PHENYLEPHRINE (NEOSYNEPHRINE) 0.5% NS,1401720,CDM,250,RC,,,outpatient,,,17.48,10.49,,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,15.73,
PHENYLEPHRINE HCL 30MG/GUAIFENESIN 600MG,1401050,CDM,250,RC,,,outpatient,,,7.96,4.78,,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,7.16,
PHENYLEPHRINE NOSE DROPS 1/2%,1401305,CDM,250,RC,,,outpatient,,,19.89,11.93,,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.08,17.9,
PHENYLEPHRINE NOSE SPRAY (APPLI) ER USE,1402674,CDM,250,RC,,,outpatient,,,5.3,3.18,,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,4.77,
PHENYLEPHRINE*20MG/GUAIFENESIN 300MG**,1402323,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PHENYTOIN (DILANTIN) 100MG CAP,1400180,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PHENYTOIN (DILANTIN) 100MG/4ML UD SUSP,1402213,CDM,250,RC,,,outpatient,,,27.26,16.36,,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,24.53,
PHENYTOIN SUSP 125MG/5ML,1400182,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
PHYTONADIONE TAB 5MG,1401558,CDM,250,RC,,,outpatient,,,3.82,2.29,,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,3.44,
PILOCARPINE OPHTH SOLN 1%,1400500,CDM,250,RC,,,outpatient,,,57.09,34.25,,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,51.38,
PILOCARPINE OPHTH SOLN 2%,1401439,CDM,250,RC,,,outpatient,,,56.83,34.1,,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.64,51.15,
PIMECROLIMUS CREAM 1%,1402419,CDM,250,RC,,,outpatient,,,277.01,166.21,,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,174.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.76,249.31,
PINDOLOL TAB 5MG,1400130,CDM,250,RC,,,outpatient,,,4.99,2.99,,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,4.49,
PIOGLITAZONE (ACTOS) 15MG TAB,1402108,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
PIPERACILLIN/TAZO (ZOSYN) 2.25GM VIAL,1403988,CDM,250,RC,,,outpatient,,,16.12,9.67,,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,14.51,
PIPERACILLIN/TAZO (ZOSYN) 3.375GM VIAL,1402086,CDM,250,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
PIPERACILLIN/TAZO (ZOSYN) 4.5GM (VIAL),1404010,CDM,250,RC,,,outpatient,,,93.98,56.39,,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,84.58,
PIPERACILLIN/TAZO(ZOSYN) 2.25GM/NS100ML,1402737,CDM,250,RC,,,outpatient,,,71.03,42.62,,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,63.93,
PIPERACILLIN/TAZOBACTAM:3375MG (FROZEN),1402123,CDM,250,RC,,,outpatient,,,115.37,69.22,,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,103.83,
PITRESSIN INJ 20 UNITS,1401229,CDM,250,RC,,,outpatient,,,264.16,158.5,,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.13,237.74,
POLYETHYLENE GLYCOL (MIRALAX) 17GM PKT,1402610,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
POLYETHYLENE GLYCOL (MIRALAX) 238GM DOSE,1404673,CDM,250,RC,,,outpatient,,,20.16,12.1,,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,18.14,
POLYMIXIN B SULF/TRIMETHOPRIM (POLYTRIM),1402615,CDM,250,RC,,,outpatient,,,63.1,37.86,,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,56.79,
POLYSACCHARIDE IRON (NU-IRON) 150MG CAP,1400937,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
POLYSPORIN OPHTH OINT,1401698,CDM,250,RC,,,outpatient,,,68.54,41.12,,51.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.04,61.69,
POTASSIUM ACETATE:2MEQ/ML INJ 20ML,1401803,CDM,250,RC,,,outpatient,,,42.89,25.73,,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,38.6,
POTASSIUM ACID PHOSPHATE (NA FREE),1401959,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
POTASSIUM CHLORIDE (K-DUR) 20MEQ TAB,1401501,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
POTASSIUM CHLORIDE (KLOR CON) 10MEQ TAB,1401079,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
POTASSIUM CHLORIDE (KLOR CON) 8MEQ TAB,1400967,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
POTASSIUM IODIDE (SSKI) 1G/ML DROPS 14ML,1402589,CDM,250,RC,,,outpatient,,,153.25,91.95,,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.4,137.93,
POTASSIUM PHOSPHATE (K-PHOS) 500MG TAB,1404728,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
POTASSIUM PHOSPHATE:4.4MEQ/ML INJ 15ML,1401802,CDM,250,RC,,,outpatient,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,6.15,
PRAMIPEXOLE (MIRAPEX) 0.25MG TAB,1402734,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PRAMOXINE/HYDROCORT (EPIFOAM) TOP FOAM,1401788,CDM,250,RC,,,outpatient,,,119.88,71.93,,89.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.56,107.89,
PRAVASTATIN (PRAVACHOL) 20MG TAB,1402012,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PRAZOSIN (MINIPRES) 1MG CAPSULE,5376,CDM,250,RC,,,outpatient,,,6.12,3.67,,4.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,5.51,
PREDNISOLONE (PRED FORTE) OPHTH SUSP 1%,1401310,CDM,250,RC,,,outpatient,,,314.65,188.79,,235.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,198.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.47,283.19,
PREDNISOLONE (PRELONE) 15MG/5ML SYR (ER),1402644,CDM,250,RC,,,outpatient,,,2.39,1.43,,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,2.15,
PREDNISOLONE (PRELONE) 15MG/5ML SYRUP,1401660,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
"PREDNISOLONE SOD,PHOSPHATE OPHTN SOLN 1%",1401314,CDM,250,RC,,,outpatient,,,81.41,48.85,,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,73.27,
PREDNISONE 20MG TAB,1401123,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PREDNISONE 5MG TAB,1400492,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PREGABALIN (LYRICA) 50MG CAP,1402559,CDM,250,RC,,,outpatient,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,6.63,
PREGABALIN CAP 100MG,1402560,CDM,250,RC,,,outpatient,,,11.14,6.68,,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,10.03,
PREGABALIN(LYRICA) 75MG,1402571,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PRENATAL VITAMIN TAB,1400605,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PRENATE GT,1402401,CDM,250,RC,,,outpatient,,,3.55,2.13,,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,3.2,
PREPARATION-H OINT 60GM,1400550,CDM,250,RC,,,outpatient,,,79.71,47.83,,59.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.33,71.74,
PRIMIDONE (MYSOLINE) 250MG TAB,1400400,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PRIMIDONE (MYSOLINE) 50MG TAB,1402218,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PROBENECID TAB 500MG,1400114,CDM,250,RC,,,outpatient,,,4.88,2.93,,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,4.39,
PROBIOTIC COMPLEX CAP,1403971,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PROCALAMINE 1000ML,1402085,CDM,250,RC,,,outpatient,,,194.51,116.71,,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,122.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.86,175.06,
PROCHLORPERAZINE (COMPAZINE) 25 MG SUPP,1404069,CDM,250,RC,,,outpatient,,,35.51,21.31,,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,31.96,
PROCHLORPERAZINE (COMPAZINE) 5MG/ML 2ML,1404070,CDM,250,RC,J0780,HCPCS,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,23.12,
PROCHLORPERAZINE SPAN. 10MG,1401793,CDM,250,RC,,,outpatient,,,11.77,7.06,,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,10.59,
PROCLORPERAZINE (COMPAZINE) 10MG TAB,1400791,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PROCTOFOAM HC SPRAY,1404048,CDM,250,RC,,,outpatient,,,237.39,142.43,,178.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,149.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.64,213.65,
PROMETHAXIN EW. DETXTROMETH S,1401517,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
PROMETHAZINE (PHENERGAN) 25MG SUPP,1400497,CDM,250,RC,,,outpatient,,,30.32,18.19,,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,27.29,
PROMETHAZINE (PHENERGAN) 25MG TAB,1400499,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PROMETHAZINE 25MG/NS 50ML IVPB,1404623,CDM,250,RC,,,outpatient,,,16.39,9.83,,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,14.75,
PROMETHAZINE HCL SUPP 12.5MG,1401462,CDM,250,RC,,,outpatient,,,20.69,12.41,,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,18.62,
PROPARACAINE 0.5% OPHTH SOLN,1402110,CDM,250,RC,,,outpatient,,,102.44,61.46,,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.99,92.2,
PROPOFOL (DIPRIVAN) 10MG/ML 50ML INJ,1403982,CDM,250,RC,,,outpatient,,,21.31,12.79,,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,19.18,
PROPOXYPHENE NAP 100MG/APAP 650MG,1400015,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
PROPRANOLOL (INDERAL) 10MG TAB,1401060,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PROPRANOLOL TAB 20MG,1401059,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
PSEUDOEPHEDRINE S.A. TAB 120MG,1401171,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
PSEUDOEPHEDRINE TAB 30MG,1400597,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
PSYLLIUM FIBER (METAMUCIL) 5G PKT,1400772,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
PYRIDOSTIGMINE (MESTINON) 60MG TABLET,5526,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
PYRIDOSTIGMINE*BROMIDE 180MG TIMESPAN**,1402277,CDM,250,RC,,,outpatient,,,8.76,5.26,,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.88,
PYRIDOXINE (VIT B6) 50MG TAB,1401377,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
QUETIAPINE (SEROQUEL) 100MG TAB,1402122,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
QUETIAPINE (SEROQUEL) 25MG TAB,1402063,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
QUINAPRIL (ACCUPRIL) 40MG TAB,3650,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
QUINIDINE GLUCONATE INJ 80MG/ML,1400525,CDM,250,RC,,,outpatient,,,41.52,24.91,,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,37.37,
RABEPRAZOLE*SOD. 20MG(NP) **,1402239,CDM,250,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
RACEPINEPHRINE 2.25% 0.5ML NEBS,1402200,CDM,250,RC,,,outpatient,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.12,4.91,
RALOXIFENE (EVISTA) 60MG TAB,1402068,CDM,250,RC,,,outpatient,,,30.54,18.32,,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,27.49,
RAMIPRIL CAP 5MG,1401990,CDM,250,RC,,,outpatient,,,6.79,4.07,,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.39,6.11,
RANITIDINE (ZANTAC) 150MG/10ML SYRUP,1401988,CDM,250,RC,,,outpatient,,,9.38,5.63,,7.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,8.44,
RANOLAZINE ER (RANEXA) 500MG TAB,1402766,CDM,250,RC,J8499,HCPCS,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
REG. U-100 INSULIN,1401365,CDM,250,RC,,,outpatient,,,0.96,0.58,,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,0.86,
RIFAMPIN 300MG/ISONIAZID 150MG CAP,1401551,CDM,250,RC,,,outpatient,,,22.55,13.53,,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.62,20.3,
RIFAMPIN CAP 300MG,1401799,CDM,250,RC,,,outpatient,,,11.21,6.73,,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,10.09,
RIMANTADINE HCL 100MG,1402080,CDM,250,RC,,,outpatient,,,12.51,7.51,,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,11.26,
RISPERIDONE (RISPERDAL) 0.25MG TAB,1402433,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
RISPERIDONE (RISPERDAL) 1MG TAB,1401943,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
RISPERIDONE ORAL SOLN 1MG/ML,1402126,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
RIVAROXABAN (XARELTO) 10MG TAB,1404045,CDM,250,RC,,,outpatient,,,66.12,39.67,,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,59.51,
RIVASTIGMINE (EXELON) 1.5MG CAP,1402609,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ROCURONIUM (ZEMURON) 10MG/ML 5ML INJ,1402474,CDM,250,RC,,,outpatient,,,77.04,46.22,,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,69.34,
ROCURONIUM 500MG/D5W 1000ML,5868,CDM,250,RC,,,outpatient,,,77.04,46.22,,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,69.34,
RONDEC SYRUP,1402573,CDM,250,RC,,,outpatient,,,5.57,3.34,,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,5.01,
ROPINIROLE (REQUIP) 0.5MG TAB,1402561,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ROPINIROLE (REQUIP) 2MG TAB,1402765,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ROPIVACAINE (NAROPIN) 0.2% 2MG/ML 100ML,1402689,CDM,250,RC,,,outpatient,,,159.26,95.56,,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,143.33,
ROPIVACAINE (NAROPIN) 0.5% 5MG/ML 20ML,1402690,CDM,250,RC,,,outpatient,,,59.95,35.97,,44.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.28,53.96,
ROPIVACAINE (NAROPIN) 0.5% 5MG/ML 30ML,1404702,CDM,250,RC,,,outpatient,,,111.13,66.68,,83.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.77,100.02,
ROPIVACAINE (NAROPIN) 2MG/ML 0.2% 20ML,1402761,CDM,250,RC,,,outpatient,,,39.89,23.93,,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,35.9,
ROSUVASTATIN CALCIUM 10MG,1402701,CDM,250,RC,,,outpatient,,,14.58,8.75,,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,13.12,
ROSUVASTATIN CALCIUM 20MG,1402700,CDM,250,RC,,,outpatient,,,15.65,9.39,,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,14.09,
SALINE NASAL DROPS,1401896,CDM,250,RC,,,outpatient,,,12.63,7.58,,9.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.59,11.37,
SALMETEROL XINAFOATE INH POWDER DISKUS,1401974,CDM,250,RC,,,outpatient,,,294.09,176.45,,220.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,220.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,185.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.26,264.68,
SCOPOLAMINE (TRANSDERM SCOP) 1MG PATCH,1402594,CDM,250,RC,,,outpatient,,,88.51,53.11,,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,79.66,
SCOPOLAMINE INJ 0.4MG/ML,1400761,CDM,250,RC,,,outpatient,,,82.77,49.66,,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,74.49,
SENNA (SENOKOT) 8.6MG TAB,1401136,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SERTRALINE (ZOLOFT) 50MG TAB,1401850,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SEVELAMER HCL 800MG,1402582,CDM,250,RC,,,outpatient,,,9.29,5.57,,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,8.36,
SILVER NITRATE APPLICATOR,1401806,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SILVER SULFADIAZINE (SILVADENE)1%CR 25GM,1404652,CDM,250,RC,,,outpatient,,,21.86,13.12,,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,19.67,
SILVER SULFADIAZINE (SILVADENE)1%CR400GM,1400919,CDM,250,RC,,,outpatient,,,131.13,78.68,,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.87,118.02,
SILVER SULFADIAZINE CR. (UD) ER USE,1402637,CDM,250,RC,,,outpatient,,,3.55,2.13,,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,3.2,
SIMETHICONE (MYLICON) 40MG/0.6ML (ER),1402657,CDM,250,RC,,,outpatient,,,3.83,2.3,,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,3.45,
SIMETHICONE (MYLICON) 40MG/0.6ML DR 30ML,1402191,CDM,250,RC,,,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,25.82,
SIMETHICONE (MYLICON) 80MG TABS,1400965,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SIMETHICONE/ALUM/MAG.HYDROXIDE SUSP UD,1401346,CDM,250,RC,,,outpatient,,,5.19,3.11,,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.67,
SITAGLIPTIN (JANUVIA) 25MG TAB,1402768,CDM,250,RC,,,outpatient,,,32.96,19.78,,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,29.66,
SLOW-FE TAB,1401141,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
SOD CIT/CIT ACID (BICITRA) 15ML UD,1402236,CDM,250,RC,,,outpatient,,,7.08,4.25,,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,6.37,
SOD FERRIC GLUCONATE:12.5MG/1ML,1402557,CDM,250,RC,,,outpatient,,,46.95,28.17,,35.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.62,42.26,
SOD PHOS/K PHOS PWD (NEUTRA PHOS) PWD,1401599,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SOD POLYSTYRENE (KAYEXALATE) 15GM/60ML,1402237,CDM,250,RC,,,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.54,
SOD.CITRATE/CITRIC ACID SOLN,1400177,CDM,250,RC,,,outpatient,,,3.4,2.04,,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,3.06,
SODIUM BICARB 4.2% (0.5MEQ/ML) 10ML INJ,1400566,CDM,250,RC,,,outpatient,,,17.21,10.33,,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,15.49,
SODIUM BICARB 8.4% 1MEQ/ML 50ML ABBJ.,1401393,CDM,250,RC,,,outpatient,,,95.61,57.37,,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.59,86.05,
SODIUM BICARBONATE 650MG TAB,1401160,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SODIUM BICARBONATE 8.4% 50ML (VIAL),1403962,CDM,250,RC,,,outpatient,,,38.19,22.91,,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,34.37,
SODIUM BICARBONATE INJ 4% 5ML,1402037,CDM,250,RC,,,outpatient,,,50.6,30.36,,37.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.37,45.54,
SODIUM CHLORIDE (AYR) 0.65% NASAL MIST,1401895,CDM,250,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
SODIUM CHLORIDE 0.9% (BACT) 30ML VIAL,1400570,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SODIUM CHLORIDE 0.9% 10ML PF VIAL,1401430,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SODIUM CHLORIDE 0.9% 10ML SYRINGE,1402730,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SODIUM CHLORIDE 1GM TAB,1400796,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SODIUM CHLORIDE CONC 23.4% 4MEQ/ML 30ML,1401901,CDM,250,RC,,,outpatient,,,24.04,14.42,,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,21.64,
SODIUM CHLORIDE INJ (PF) 5ML SYRINGE,1402731,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
SODIUM HYALURONATE(SUPARTZ) 25MG/2.5ML,1402776,CDM,250,RC,,,outpatient,,,367.15,220.29,,275.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,275.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.23,330.44,
SODIUM HYPOCHLORITE (DAKINS 1/2) 0.25%,1403990,CDM,250,RC,,,outpatient,,,63.65,38.19,,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,57.29,
SODIUM HYPOCHLORITE (DAKINS 1/4)0.125%,4802,CDM,250,RC,,,outpatient,,,29.69,17.81,,22.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,26.72,
SODIUM PHOSPHATE 3MM/ML 5ML INJ,1402733,CDM,250,RC,,,outpatient,,,70.75,42.45,,53.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.5,63.68,
SODIUM PHOSPHATE: 3 MM/ML 15 ML,1404051,CDM,250,RC,,,outpatient,,,42.89,25.73,,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,38.6,
SOLIFENACIN (VESICARE) 5MG TAB,1402770,CDM,250,RC,,,outpatient,,,26.5,15.9,,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,23.85,
SORBITOL 70% UD 30ML,1402233,CDM,250,RC,,,outpatient,,,8.2,4.92,,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,7.38,
SOTALOL (BETAPACE) 80MG TAB,1402203,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SPIRONOLACTONE (ALDACTONE) 25MG TAB,1400041,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
STERILE WATER FOR INJ 10ML VIAL,1401183,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
STERILE WATER FOR INJ 20ML VIAL,1405660,CDM,250,RC,,,outpatient,,,4.92,2.95,,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,4.43,
SUCRALFATE (CARAFATE) 1GM TAB,1400927,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SUCRALFATE 1GM/10ML SUSP,1402588,CDM,250,RC,,,outpatient,,,30.24,18.14,,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,27.22,
SUFENTANIL INJ 50MCG/ML 2ML,1400871,CDM,250,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
SUGAMMADEX (BRIDION) 100MG/ML 2ML VIAL,1404597,CDM,250,RC,,,outpatient,,,253.24,151.94,,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,159.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.89,227.92,
SULFA/TRIMETH (BACTRIM DS) 800/160 TAB,1400108,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SULFA/TRIMETH (BACTRIM)200-40MG/5ML 20ML,1400109,CDM,250,RC,,,outpatient,,,30.24,18.14,,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.2,27.22,
SULFAMETH/TRIM (BACTRIM) 800/160 VIAL,1400892,CDM,250,RC,,,outpatient,,,49.99,29.99,,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,44.99,
SULFASALAZINE (AZULFIDINE) 500MG TAB,1402581,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SUMATRIPTAN (IMITREX) 25MG TAB,1404616,CDM,250,RC,,,outpatient,,,2.18,1.31,,1.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.45,1.96,
"SYNTHETIC CONJUGATED ESTROGENS,A 1.25MG",1402444,CDM,250,RC,,,outpatient,,,7.85,4.71,,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,7.07,
TAMOXIFEN TAB 10MG,1400978,CDM,250,RC,,,outpatient,,,5.09,3.05,,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,4.58,
TAMSULOSIN (FLOMAX) 0.4MG CAP,1402062,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TEARS PLUS OPHTH SOLN,1401308,CDM,250,RC,,,outpatient,,,55.96,33.58,,41.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,50.36,
TEMAZEPAM (RESTORIL) 15MG CAP,1400938,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TERAZOSIN (HYTRIN) 2MG CAPSULE,1401459,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TERBINAFINE*HCL TAB 250MG*,1402296,CDM,250,RC,,,outpatient,,,77.04,46.22,,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,69.34,
TERBUTALINE TAB 2.5MG,1400118,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
TERBUTALINE TAB 2.5MG,1401026,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
TERCONAZOLE (TERAZOL) 0.4% VAG CR 45G,1401000,CDM,250,RC,,,outpatient,,,133.26,79.96,,99.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,119.93,
TETRACAINE HCL OPHTH OINT,1400487,CDM,250,RC,,,outpatient,,,64.5,38.7,,48.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.22,58.05,
TETRACAINE HCL OPHTH SOLN 0.5% 4ML,1401311,CDM,250,RC,,,outpatient,,,43.17,25.9,,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,38.85,
TETRACAINE OPHTH SOLN 0.5% (APPLICATION),1401447,CDM,250,RC,,,outpatient,,,31.3,18.78,,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,28.17,
Tetracaine Ophth Soln 5% (10ML),1401441,CDM,250,RC,,,outpatient,,,68.02,40.81,,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,61.22,
TETRAHYDROZOLINE(VISINE)0.05% OPHTH 15ML,1400693,CDM,250,RC,,,outpatient,,,27.26,16.36,,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.59,24.53,
THEOPHYLLINE ER (THEO-24) 200MG CAP,4948,CDM,250,RC,,,outpatient,,,13.11,7.87,,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,11.8,
THEOPHYLLINE ER (THEODUR) 300MG TAB,1400777,CDM,250,RC,,,outpatient,,,9.82,5.89,,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,8.84,
THEOPHYLLINE LIQ 80MG/15ML,1400939,CDM,250,RC,,,outpatient,,,16.39,9.83,,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.36,14.75,
THEOPHYLLINE S.A. TAB 200MG,1400866,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
THERAGRAN HEMATINIC,1400763,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
THERAGRAN LIQ.,1400831,CDM,250,RC,,,outpatient,,,4.65,2.79,,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,4.19,
THERAPEUTIC MULTIVITAMIN (THERAGRAN) TAB,1400638,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
THIAMINE (VITAMIN B-1) 100MG TAB,1400640,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
THROMBINAR SPRAY KIT,1401371,CDM,250,RC,,,outpatient,,,1517.8,910.68,,1138.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1214.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,323.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,323.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1138.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1366.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1138.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,956.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311,1366.02,
TICAGRELOR (BRILINTA) 90MG TAB,5462,CDM,250,RC,,,outpatient,,,26,15.6,,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,23.4,
TICARCILLIN/CLAVULANATE:3100MG IV,1401856,CDM,250,RC,,,outpatient,,,49.59,29.75,,37.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,44.63,
TIMENTIN 3.1GM/NS 100ML IVPB,1401111,CDM,250,RC,J0295,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,3.2,
TIMOLOL (TIMOPTIC) 0.25% OS 10ML,1400916,CDM,250,RC,,,outpatient,,,21.31,12.79,,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,19.18,
TIMOLOL OPHTH SOLN 0.5%,1400917,CDM,250,RC,,,outpatient,,,77.34,46.4,,58.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.85,69.61,
TISSEEL GLUE 1501236,2109715,CDM,250,RC,J3590,HCPCS,outpatient,,,241.14,144.68,,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.41,217.03,
TIZANIDINE (ZANAFLEX) 4MG TAB,1402772,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TOBRAMYCIN (TOBREX) 0.3% OPHTH OINT 3.5G,1401904,CDM,250,RC,,,outpatient,,,322.08,193.25,,241.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,202.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.99,289.87,
TOBRAMYCIN OPHTH SOLN. 0.3%,1401705,CDM,250,RC,,,outpatient,,,68.22,40.93,,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,61.4,
TOBRAMYCIN/DEXAMETH (TOBRADEX) OPH OINT,1401707,CDM,250,RC,,,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,221.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,315.94,
TOBRAMYCIN/DEXAMETH (TOBRADEX) OPH SUSP,1401706,CDM,250,RC,,,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,132.28,
TOPIRAMATE (TOPAMAX) 25MG TAB,1402188,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TORSEMIDE (DEMADEX) 10MG TAB,1401979,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TRAMADOL (ULTRAM) 50MG TAB,1401993,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TRANEXAMIC ACID 100MG/ML 10ML INJ,1403974,CDM,250,RC,,,outpatient,,,51.63,30.98,,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,46.47,
TRAZODONE (DESYREL) 50MG TAB,1400862,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TRAZODONE TAB 100MG,1400877,CDM,250,RC,,,outpatient,,,3.29,1.97,,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,2.96,
TRIAMCINOLONE (KENALOG) 0.1% CREAM 15GM,1400303,CDM,250,RC,,,outpatient,,,14.15,8.49,,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.9,12.74,
TRIAMCINOLONE (KENALOG) 0.1% CREAM 1LB,1402352,CDM,250,RC,,,outpatient,,,80.81,48.49,,60.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.56,72.73,
TRIAMCINOLONE CR. 0.1% (APPL)(ER USE),1402647,CDM,250,RC,,,outpatient,,,7.16,4.3,,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,6.44,
TRIAMCINOLONE IN ORABASE,1400304,CDM,250,RC,,,outpatient,,,33.33,20,,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,30,
TRIAMCINOLONE NASAL INHALER,1401781,CDM,250,RC,,,outpatient,,,359.51,215.71,,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,323.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,226.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.66,323.56,
TRIAMTERENE AND HCTZ 37.5MG-25 TABLET,3783,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
TRIAMTERENE/HCTZ (DYAZIDE) 37.5/25MG CAP,1400198,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TRIAMTERENE/HCTZ (MAXZIDE) 37.5/25MG TAB,1400366,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TRIFLUOPERAZINE TAB 2MG,1401582,CDM,250,RC,,,outpatient,,,11.45,6.87,,8.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,10.31,
Trihexyphenidyl (ARTANE) 2MG TAB,5813,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
TRIMETH/SULFA (BACTRIM) 200-40MG/5ML(ER),1402643,CDM,250,RC,,,outpatient,,,1.65,0.99,,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.34,1.49,
TRIMETHOBENZAMIDE 250MG,1400649,CDM,250,RC,,,outpatient,,,4.78,2.87,,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,4.3,
TRIMETHOBENZAMIDE PED SUPP 100MG,1401359,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
TRIMETHOBENZAMIDE SUPP 200MG,1400651,CDM,250,RC,,,outpatient,,,6.1,3.66,,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,5.49,
TRIPLE DYE U-D,1400940,CDM,250,RC,,,outpatient,,,3.98,2.39,,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.82,3.58,
TROLAMINE SALICYLATE CREAM 10%,1400399,CDM,250,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
TRYPAN BLUE OPH SOLN 0.06% 0.5ML,1402551,CDM,250,RC,,,outpatient,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,173.58,
TUCKS,2100165,CDM,250,RC,,,outpatient,,,66.65,39.99,,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,59.99,
TUSSIONEX SUSP,1400671,CDM,250,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
TYLENOL EL 160MG/5 ML,1404046,CDM,250,RC,,,outpatient,,,3.55,2.13,,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,3.2,
TYLENOL FOR INFANTS 160MG/5ML (ER USE),1402659,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
TYMPAGESIC OTIC DROPS (APPL) (ER USE),1402655,CDM,250,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
URINARY ANTISEPTIC TAB,1400682,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
VALACYCLOVIR (VALTREX) 500MG TAB,1402087,CDM,250,RC,,,outpatient,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,6.63,
VALPROATE INJ 500MG,1402748,CDM,250,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
VALPROIC ACID (DEPAKENE) 250MG/5ML UD,1402576,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
VALPROIC ACID CAP 250MG,1400754,CDM,250,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
VALSARTAN (DIOVAN) 80MG TAB,1402073,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
VANCOMYCIN (VANCOCIN) 250MG CAPSULE,1404026,CDM,250,RC,,,outpatient,,,56.55,33.93,,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,50.9,
VANCOMYCIN 1.25GM VIAL,1404654,CDM,250,RC,J3370,HCPCS,outpatient,,,82.77,49.66,,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,52.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,74.49,
VANCOMYCIN 1.5GM INJ (VIAL),1404614,CDM,250,RC,J3370,HCPCS,outpatient,,,94.52,56.71,,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,59.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,85.07,
VANCOMYCIN 1GM PREMIX,1404729,CDM,250,RC,J3370,HCPCS,outpatient,,,49.44,29.66,,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,31.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,44.5,
VANCOMYCIN 1GM/NS 250ML IVPB,1402797,CDM,250,RC,J3370,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,3.92,
VANCOMYCIN 750 MG VIAL,1404608,CDM,250,RC,J3370,HCPCS,outpatient,,,30.32,18.19,,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,27.29,
VANCOMYCIN SUSP 250MG/5ML,1403959,CDM,250,RC,,,outpatient,,,8.76,5.26,,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.88,
VASOCON-A OPHTH SOLN,1401996,CDM,250,RC,,,outpatient,,,29.18,17.51,,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,26.26,
VASOPRESSIN INJ 20 UNITS/ML,1401908,CDM,250,RC,,,outpatient,,,373.99,224.39,,280.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.63,336.59,
VECURONIUM BROMIDE INJ 10MG,1401368,CDM,250,RC,,,outpatient,,,427.27,256.36,,320.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,320.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,320.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,269.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.55,384.54,
VENLAFAXINE (EFFEXOR ) 37.5 MG TAB,1404653,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
VENLAFAXINE XR (EFFEXOR XR) 37.5 MG CAP,1402127,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
VERAPAMIL (CALAN) 2.5MG/ML 2ML INJ,1400925,CDM,250,RC,,,outpatient,,,93.43,56.06,,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.14,84.09,
VERAPAMIL (CALAN) 80MG TAB,1400923,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
Verapamil (CALAN) SR 180MG CAPLET,3976,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
Verapamil (CALAN) SR 180MG CAPLET,1404667,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
VERAPAMIL SR (CALAN SR) 120MG CAP,1401683,CDM,250,RC,,,outpatient,,,16.97,10.18,,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,15.27,
VERAPAMIL TAB 40MG,1401479,CDM,250,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
VIALMATES,1404627,CDM,250,RC,,,outpatient,,,9.18,5.51,,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,8.26,
VISCOELASTIC SYSTEM,1402115,CDM,250,RC,,,outpatient,,,812.71,487.63,,609.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,173.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,609.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,731.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,609.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,512.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.52,731.44,
VITAMIN A & D OINT,1402572,CDM,250,RC,,,outpatient,,,17.48,10.49,,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,15.73,
VITAMIN B COMPLEX CAP,1401753,CDM,250,RC,,,outpatient,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.69,
VITAMIN E 200 I.U. CAP,1402189,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
VITAMIN K TAB 5MG TABLET,1400830,CDM,250,RC,,,outpatient,,,87.42,52.45,,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.91,78.68,
WARFARIN (COUMADIN) 1MG TAB,1402429,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
WARFARIN (COUMADIN) 2.5MG TAB,1401381,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
WARFARIN (COUMADIN) 5MG TAB,1400145,CDM,250,RC,,,outpatient,,,5.57,3.34,,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,5.01,
WATER FOR IRRIGATION 500ML,1404612,CDM,250,RC,,,outpatient,,,39.87,23.92,,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,35.88,
xxATORVASTATIN (LIPITOR) 80MG TAB,1402744,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
XXVANCOMYCIN:500MG /D5W 100ML (FROZEN),1402564,CDM,250,RC,J3370,HCPCS,outpatient,,,29.97,17.98,,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,26.97,
XYLOCAINE 1% 2ML,1400723,CDM,250,RC,,,outpatient,,,82.77,49.66,,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,74.49,
ZALEPLON CAP*10MG **,1402428,CDM,250,RC,,,outpatient,,,13.47,8.08,,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,12.12,
ZIDOVUDINE (RETROVIR) 100MG CAP,1401667,CDM,250,RC,,,outpatient,,,4.92,2.95,,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,4.43,
ZINC OXIDE (BEAUDROUX BUTT PASTE),1400034,CDM,250,RC,,,outpatient,,,19.67,11.8,,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,17.7,
ZINC OXIDE 20% OINTMENT 30GM,1400692,CDM,250,RC,,,outpatient,,,8.69,5.21,,6.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,7.82,
ZINC OXIDE PASTE,1401340,CDM,250,RC,,,outpatient,,,15.81,9.49,,11.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,14.23,
Zinc Sulfate Capsule 220MG,5774,CDM,250,RC,,,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,3.82,
Zinc Sulfate Capsule 220MG,1404663,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ZIPRASIDONE (GEODON) 20MG CAP,1402152,CDM,250,RC,,,outpatient,,,9.84,5.9,,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,8.86,
ZITHROMAX 500MG/NS 250ML IVPB,1499995,CDM,250,RC,,,outpatient,,,161.18,96.71,,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,145.06,
ZITHROMAX SUSP 200MG/5ML (1ML) ER USE,1402635,CDM,250,RC,,,outpatient,,,6.56,3.94,,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,5.9,
ZOLMITRIPTAN NASAL SPRAY*MG,1402447,CDM,250,RC,,,outpatient,,,468.6,281.16,,351.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,351.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,351.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,295.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.02,421.74,
ZOLPIDEM (AMBIEN) 5MG TABLET,1401919,CDM,250,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
ZOSYN 4.5GM/NS 100ML IVPB,1404011,CDM,250,RC,,,outpatient,,,93.98,56.39,,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,84.58,
GASTROGRAFIN (CHARGE ITEM),1401804,CDM,255,RC,,,outpatient,,,64.93,38.96,,48.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.3,58.44,
GASTROGRAFIN 120ML,1402682,CDM,255,RC,,,outpatient,,,233.31,139.99,,174.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,146.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.81,209.98,
MAGNEVIST 46.9% 1ML,1402749,CDM,255,RC,A9579,HCPCS,outpatient,,,28.41,17.05,,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.56,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,25.57,
NM TC99M MDP UP TO 30 MCI/DOSE,1600116,CDM,255,RC,A9503,HCPCS,outpatient,,,210.08,126.05,,157.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,45.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,157.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,132.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13,189.07,
OMNIPAQUE 240 MG/ML (100ML),1404030,CDM,255,RC,Q9967,HCPCS,outpatient,,,35.63,21.38,,26.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,32.07,
OMNIPAQUE 350 MG/ML (100ML),1402727,CDM,255,RC,Q9967,HCPCS,outpatient,,,38.94,23.36,,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,35.05,
OMNIPAQUE 350MG/ML (500ML),1402747,CDM,255,RC,Q9967,HCPCS,outpatient,,,189.2,113.52,,141.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,40.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,119.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,170.28,
SEVOFLURANE (ULTANE) 250ML,1402621,CDM,255,RC,,,outpatient,,,693.88,416.33,,520.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,147.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,520.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,624.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,520.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,437.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.18,624.49,
SITZMARKS RADIOPAQUE CAPSULE,1402773,CDM,255,RC,,,outpatient,,,99.71,59.83,,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,89.74,
**AMINO ACID 8.5% W/ELECTROLYTES,1401909,CDM,258,RC,,,outpatient,,,80.21,48.13,,60.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.44,72.19,
1/2 NS 1000ML,1400027,CDM,258,RC,J7030,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,36.14,
1/2 NS W/20MEQ KCL 1000ML,1402729,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
1/4 NS 1000ML,5453,CDM,258,RC,J7030,HCPCS,outpatient,,,38.99,23.39,,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,35.09,
AMINO ACID 5% WITHOUT LYTES DEXT 20%,1402837,CDM,258,RC,,,outpatient,,,84.35,50.61,,63.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.28,75.92,
CLINIMIX E 4.25/5 1000ML,1402671,CDM,258,RC,,,outpatient,,,172.65,103.59,,129.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,108.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.38,155.39,
CLINIMIX E 4.25/5 2000ML,1404717,CDM,258,RC,,,outpatient,,,307.97,184.78,,230.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,194.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.1,277.17,
CLINIMIX E 5/20 1000ML,1402672,CDM,258,RC,,,outpatient,,,148.61,89.17,,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.45,133.75,
CLOMIPRAMINE 25MG,1402626,CDM,258,RC,,,outpatient,,,3.72,2.23,,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,3.35,
D10W 1000ML,1401473,CDM,258,RC,J7060,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.87,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.3,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,36.14,
D10W 250ML,1400999,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5 1/2 NS 1000ML,1401409,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5 1/2 NS 1000ML W/KCL 10MEQ,1401727,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5 1/2 NS 1000ML W/KCL 30MEQ,1401729,CDM,258,RC,,,outpatient,,,38.99,23.39,,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,35.09,
D5 1/2 NS 1000ML W/KCL 40MEQ,1401730,CDM,258,RC,,,outpatient,,,38.99,23.39,,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,35.09,
D5 1/2 NS 500ML,1400007,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5 1/2 NS W/KCL 20MEQ 1000ML,1401728,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5 1/4 NS 1000ML,1401813,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5 1/4 NS 250ML,1401505,CDM,258,RC,,,outpatient,,,38.99,23.39,,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,35.09,
D5 1/4 NS 500ML,1401414,CDM,258,RC,,,outpatient,,,85.61,51.37,,64.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.54,77.05,
D5 1/4 NS 500ML,1402446,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5LR 1000ML,1400008,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5NS 1000ML,1401408,CDM,258,RC,J7042,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.89,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,36.14,
D5NS 1000ML W/KCL 20MEQ,1401725,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5NS 1000ML W/KCL 40MEQ,1401726,CDM,258,RC,,,outpatient,,,38.99,23.39,,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,35.09,
D5NS 500ML,1401407,CDM,258,RC,J7042,HCPCS,outpatient,,,38.99,23.39,,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.89,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,35.09,
D5W 1000ML,1400005,CDM,258,RC,J7070,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.73,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,36.14,
D5W 1000ML (NON PVC),5928,CDM,258,RC,J7070,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.73,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.73,36.14,
D5W 1000ML W/KCL 20MEQ,1401722,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5W 1000ML W/KCL 40MEQ,1401724,CDM,258,RC,,,outpatient,,,38.99,23.39,,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.99,35.09,
D5W 100ML,1400009,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5W 250ML,1401418,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5W 500ML,1400006,CDM,258,RC,J7060,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.87,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.3,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.87,36.14,
D5W 500ML (NON PVC),1401736,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
D5W 50ML,1401417,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
FAT EMULSION IV 10% 500ML,1401777,CDM,258,RC,,,outpatient,,,61.53,36.92,,46.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.61,55.38,
GATIFLOXACIN IV 200MG/D5W 100ML,1402140,CDM,258,RC,,,outpatient,,,166.24,99.74,,124.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,104.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.06,149.62,
GATIFLOXACIN IV 400MG/D5W 200ML,1402139,CDM,258,RC,,,outpatient,,,283.26,169.96,,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,178.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.04,254.93,
HETASTARCH 6% IN 500ML NS,1402695,CDM,258,RC,,,outpatient,,,83.59,50.15,,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,75.23,
LEVETIRACETAM (KEPPRA) 250MG TAB,1404668,CDM,258,RC,J7040,HCPCS,outpatient,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.36,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,3.82,
MOXIFLOXACIN IV 400MG/NS 250ML,1402183,CDM,258,RC,,,outpatient,,,147.78,88.67,,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,133,
NS 0.9% 25ML,1401935,CDM,258,RC,,,outpatient,,,19.63,11.78,,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,17.67,
NS 1000ML,1401412,CDM,258,RC,J7030,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,36.14,
NS 100ML,1401410,CDM,258,RC,,,outpatient,,,20.22,12.13,,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,18.2,
NS 100ML MINI BAG PLUS,1402219,CDM,258,RC,,,outpatient,,,20.22,12.13,,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,18.2,
NS 250ML,1401413,CDM,258,RC,J7050,HCPCS,outpatient,,,20.22,12.13,,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.68,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,18.2,
NS 500ML,1401411,CDM,258,RC,J7040,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.36,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.36,36.14,
NS 50ML,1401416,CDM,258,RC,,,outpatient,,,20.22,12.13,,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,18.2,
NS 50ML MINI BAG PLUS,1402220,CDM,258,RC,,,outpatient,,,20.22,12.13,,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,18.2,
NS W/KCL 20MEQ 1000ML,1401930,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
NS W/KCL 40MEQ 1000ML,1402556,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
SODIUM CHLORIDE 3% 500ML,1402563,CDM,258,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
STERILE WATER FOR INJ 1000ML,5452,CDM,258,RC,J7030,HCPCS,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.71,36.14,
FORM ACLS F-104,2103107,CDM,260,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,408,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408,408,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",2500125,CDM,260,RC,96375,HCPCS,outpatient,,,93.36,56.02,,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,408,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",2500126,CDM,260,RC,96376,HCPCS,outpatient,,,93.36,56.02,,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,408,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",2500124,CDM,260,RC,96374,HCPCS,outpatient,,,473.16,283.9,,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,100.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,425.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,425.84,
INJECTION IM/SQ,2500038,CDM,260,RC,96372,HCPCS,outpatient,,,127.72,76.63,,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,114.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,408,
IV HYDRATION 1ST HOUR,1000032,CDM,260,RC,96360,HCPCS,outpatient,,,453.76,272.26,,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,96.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,408.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,408.38,
IV HYDRATION EA ADD L HOUR,1000033,CDM,260,RC,96361,HCPCS,outpatient,,,127.72,76.63,,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,114.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,408,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",2500059,CDM,260,RC,96366,HCPCS,outpatient,,,51.5,30.9,,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.55,408,
IV INF HYDRATION 31MIN-1HR,2500117,CDM,260,RC,96360,HCPCS,outpatient,,,473.16,283.9,,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,100.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,425.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,425.84,
IV INF HYDRATION EA ADDNL HR,2500118,CDM,260,RC,96361,HCPCS,outpatient,,,93.36,56.02,,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,408,
"IV INF PROF, DX INTRA-ARTERIAL",2500123,CDM,260,RC,96373,HCPCS,outpatient,,,473.16,283.9,,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,100.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,425.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,425.84,
"IV INF TX, PROF, DX ADDNL SEQ INF NEW DR",2500121,CDM,260,RC,96367,HCPCS,outpatient,,,144.28,86.57,,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.52,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,129.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.56,408,
"IV INF TX, PROF, DX CONCURRENT INF",2500122,CDM,260,RC,96368,HCPCS,outpatient,,,144.28,86.57,,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.56,408,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",2500120,CDM,260,RC,96366,HCPCS,outpatient,,,93.36,56.02,,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.13,408,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",2500119,CDM,260,RC,96365,HCPCS,outpatient,,,473.16,283.9,,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,100.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,425.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.95,425.84,
IV INFUSION HYDRATION 1ST HR,2500085,CDM,260,RC,96360,HCPCS,outpatient,,,677.74,406.64,,508.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,144.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,508.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,609.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,508.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.87,609.97,
IV INFUSION HYDRATION EA ADD HR,2500086,CDM,260,RC,96361,HCPCS,outpatient,,,127.72,76.63,,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,114.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,408,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",2500043,CDM,260,RC,96365,HCPCS,outpatient,,,649.93,389.96,,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,138.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,584.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,133.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,133.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,133.17,584.94,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",1000021,CDM,260,RC,96366,HCPCS,outpatient,,,51.5,30.9,,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.55,408,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",1000016,CDM,260,RC,96365,HCPCS,outpatient,,,649.93,389.96,,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,138.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,584.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,133.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,133.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,133.17,584.94,
IV INFUSION THERAPY SEQUENTIAL HOUR,1000040,CDM,260,RC,96367,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.52,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,408,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",1000022,CDM,260,RC,96374,HCPCS,outpatient,,,462.47,277.48,,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,98.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,416.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.76,416.22,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",2500049,CDM,260,RC,96374,HCPCS,outpatient,,,462.47,277.48,,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,98.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,416.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.76,416.22,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",2500074,CDM,260,RC,96375,HCPCS,outpatient,,,345.05,207.03,,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,73.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,310.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,408,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",1000035,CDM,260,RC,96375,HCPCS,outpatient,,,345.05,207.03,,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,73.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,310.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,408,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",2500084,CDM,260,RC,96376,HCPCS,outpatient,,,25.75,15.45,,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,408,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-same drug add on",1750025,CDM,260,RC,96376,HCPCS,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,408,
THROMBOLYSIS CORONARY BY IV INFUSION,2500116,CDM,260,RC,92977,HCPCS,outpatient,,,722.47,433.48,,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,577.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,380.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,153.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,155.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,298.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,650.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,408,100,,,case rate,100% UHC case rate for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,1459.9,
ABD BINDER LG MDS169028,2100258,CDM,270,RC,,,outpatient,,,192.6,115.56,,144.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.46,173.34,
ABD BINDER MED 30-45X12 MDS169026,2101515,CDM,270,RC,,,outpatient,,,159.54,95.72,,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,143.59,
ABD BINDER SMALL 30-45X9 MDS169022,2101513,CDM,270,RC,,,outpatient,,,192.32,115.39,,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,173.09,
ABD BINDER XLG 46-62X9,2101514,CDM,270,RC,,,outpatient,,,134.4,80.64,,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,120.96,
ABD BINDER XXXLG MDS169025,2101517,CDM,270,RC,,,outpatient,,,159.54,95.72,,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,143.59,
ACE BANDAGE 2IN,2100003,CDM,270,RC,,,outpatient,,,6.56,3.94,,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,5.9,
ACE BANDAGE 3IN,2100004,CDM,270,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
ACE BANDAGE 4IN,2100005,CDM,270,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
ACE BANDAGE 6IN,2100006,CDM,270,RC,,,outpatient,,,5.15,3.09,,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.64,
ACE STERILE 2 inch,2111020,CDM,270,RC,,,outpatient,,,8.7,5.22,,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,7.83,
ACE STERILE 3 inch*,2111379,CDM,270,RC,,,outpatient,,,11.47,6.88,,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,10.32,
ACE STERILE 4 inch*,2111380,CDM,270,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
ACE STERILE 6 inch*,2111006,CDM,270,RC,,,outpatient,,,38.11,22.87,,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.81,34.3,
AEROCHAMBER ADULT,2103218,CDM,270,RC,,,outpatient,,,75,45,,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.37,67.5,
AEROSOL MASK,2600049,CDM,270,RC,,,outpatient,,,17.48,10.49,,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,15.73,
AEROSOL SETUP,2600017,CDM,270,RC,,,outpatient,,,49.99,29.99,,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,44.99,
AEROSOL TUBING,2600050,CDM,270,RC,,,outpatient,,,22.13,13.28,,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,19.92,
AIR SPLINTS RENTAL,2102473,CDM,270,RC,,,outpatient,,,38.73,23.24,,29.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.94,34.86,
AIRWAY SIZE 0 CLEAR 50MM,2102017,CDM,270,RC,,,outpatient,,,24.32,14.59,,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,21.89,
AIRWAY SIZE 00 PINK 40MM,2108972,CDM,270,RC,,,outpatient,,,21.86,13.12,,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,19.67,
AIRWAY SIZE 1 CLEAR 60MM,2102018,CDM,270,RC,,,outpatient,,,29.23,17.54,,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,26.31,
AIRWAY SIZE 2 GREEN 80MM,2102019,CDM,270,RC,,,outpatient,,,22.67,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.65,20.4,
AIRWAY SIZE 3 ORANGE 90MM,2102020,CDM,270,RC,,,outpatient,,,33.6,20.16,,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,30.24,
AIRWAY SIZE 4 RED 100MM,2102014,CDM,270,RC,,,outpatient,,,9.27,5.56,,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,8.34,
AIRWAY SIZE 5 PURPLE 120MM,2102016,CDM,270,RC,,,outpatient,,,33.6,20.16,,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,30.24,
AIRWAY SIZE 6 CLEAR 70MM,2102015,CDM,270,RC,,,outpatient,,,33.6,20.16,,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.88,30.24,
ALCON BSS PLUS 20ML,2108885,CDM,270,RC,,,outpatient,,,116.38,69.83,,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,104.74,
AMBU BAG ADULT 10-55004,2109510,CDM,270,RC,,,outpatient,,,130.59,78.35,,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.76,117.53,
AMBUBAG,2600046,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
ANES BLADE MAC 2 DISP,2109174,CDM,270,RC,,,outpatient,,,16.66,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,14.99,
ANES BLADE MAC 3 DISP,2109175,CDM,270,RC,,,outpatient,,,16.66,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,14.99,
ANES BLADE MAC 4 DISP,2109176,CDM,270,RC,,,outpatient,,,16.66,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,14.99,
ANES BLADE MILLER 1 DISP,2109171,CDM,270,RC,,,outpatient,,,16.66,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,14.99,
ANES BLADE MILLER 2 DISP,2109172,CDM,270,RC,,,outpatient,,,16.66,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,14.99,
ANES BLADE MILLER 3 DISP,2109173,CDM,270,RC,,,outpatient,,,16.66,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,14.99,
ANKLE COMPRESSION WRAP 831-GEL2,2110594,CDM,270,RC,,,outpatient,,,166.66,100,,125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.15,149.99,
ANKLE I PRO ICE PAK PI500,2111513,CDM,270,RC,,,outpatient,,,127.73,76.64,,95.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,114.96,
ARM SLING LG,2101429,CDM,270,RC,,,outpatient,,,70.48,42.29,,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,63.43,
ARM SLING MED,2101428,CDM,270,RC,,,outpatient,,,36.05,21.63,,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,32.45,
ARM SLING SM,2100246,CDM,270,RC,,,outpatient,,,70.48,42.29,,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,63.43,
ARM SLING X-SMALL,2101600,CDM,270,RC,,,outpatient,,,49.17,29.5,,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,44.25,
ARM SLING XL 79-99158,2101601,CDM,270,RC,,,outpatient,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,36.88,
ARMBOARD DALE BENDABLE INFANT SMALL,2103383,CDM,270,RC,,,outpatient,,,62.56,37.54,,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.82,56.3,
ARMBOARD DALE BENDABLE MED ADULT*,2109285,CDM,270,RC,,,outpatient,,,20.6,12.36,,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.54,
AVI FOOT COMP IMPAD LG,2111497,CDM,270,RC,,,outpatient,,,124.03,74.42,,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.41,111.63,
AVI FOOT COMP IMPAD REG 3583005065,2111496,CDM,270,RC,,,outpatient,,,163.09,97.85,,122.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.42,146.78,
AVI FOOT COMP REG REPROCESSED 5065R,2112502,CDM,270,RC,,,outpatient,,,90.97,54.58,,68.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.64,81.87,
BABY LOTION 2 OZ,2112181,CDM,270,RC,,,outpatient,,,2.74,1.64,,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.56,2.47,
BABY WASH HEAD TO TOE BABY 2OZ,2111881,CDM,270,RC,,,outpatient,,,1.09,0.65,,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,0.98,
BAIR HUGGER WHOLE BODY*,2103154,CDM,270,RC,,,outpatient,,,58.46,35.08,,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,52.61,
BEEKLEY ACCUGRID 4.65,2109138,CDM,270,RC,,,outpatient,,,150.79,90.47,,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,135.71,
BETADINE SWABSTICK,2101365,CDM,270,RC,,,outpatient,,,3.55,2.13,,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,3.2,
BILI COMBIS,2111736,CDM,270,RC,,,outpatient,,,53.54,32.12,,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,48.19,
BIPOLAR CAUTERY CABLE QD2103,2112701,CDM,270,RC,,,outpatient,,,83.33,50,,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,75,
BITE STICK,2100407,CDM,270,RC,,,outpatient,,,19.94,11.96,,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,17.95,
BLADE BEAVER 55 375522,2108870,CDM,270,RC,,,outpatient,,,132.09,79.25,,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.07,118.88,
BLADE BEAVER 66,2108869,CDM,270,RC,,,outpatient,,,132.09,79.25,,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.07,118.88,
BLADE MAC ADULT 3*,2110990,CDM,270,RC,,,outpatient,,,16.48,9.89,,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,14.83,
BLADE MAC ADULT 4*,2110991,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
BLADE MAC CHILD 2 DS.2940.150.15,2110989,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
BLADE MILLER ADULT 3*,2110988,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
BLADE MILLER CHILD 2*,2110987,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
BLADE MILLER INFANT 1 DS.2940.185.10,2110986,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
BLADE MILLER NEONATE 0 DS.2940.185.05,2110985,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
BLOOD ALCOHOL KIT,2100639,CDM,270,RC,,,outpatient,,,53.54,32.12,,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,48.19,
BLOOD WARMING BAG FENWAL,2102646,CDM,270,RC,,,outpatient,,,135.69,81.41,,101.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.8,122.12,
BLOOD WARMING BAG LEVEL I,2103021,CDM,270,RC,,,outpatient,,,438.79,263.27,,329.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,329.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,394.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,276.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.91,394.91,
BODY BAG W/HANDLES,2102833,CDM,270,RC,,,outpatient,,,280.83,168.5,,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,176.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,252.75,
BOUGIE TUBE ADULT INTRO W/COUDE TIP,2112059,CDM,270,RC,,,outpatient,,,36.62,21.97,,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,32.96,
BOUGIE TUBE ADULT INTRO W/STR TIP,2112060,CDM,270,RC,,,outpatient,,,36.62,21.97,,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,32.96,
BOUGIE TUBE PED INTRO W/COUD/STR TIP,2112458,CDM,270,RC,,,outpatient,,,36.62,21.97,,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,32.96,
BREAST PADS NURSING,2103210,CDM,270,RC,,,outpatient,,,15.85,9.51,,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,14.27,
BREATHING CIRCUIT EXT 90 inch DYNJAA1,2111542,CDM,270,RC,,,outpatient,,,19.94,11.96,,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,17.95,
BREATHING CIRCUIT PED LATEX FREE,2102297,CDM,270,RC,,,outpatient,,,33.05,19.83,,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,29.75,
BREATHING MASK OLD,2102180,CDM,270,RC,,,outpatient,,,10.38,6.23,,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,9.34,
BRIEF MESH XL 2 PK,2112079,CDM,270,RC,,,outpatient,,,1.03,0.62,,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,0.93,
BRIEF MESH XXL 2 PK,2112080,CDM,270,RC,,,outpatient,,,3.55,2.13,,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,3.2,
BUFFALO TUBING REFVT10424,2108875,CDM,270,RC,,,outpatient,,,37.71,22.63,,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,33.94,
BUTTERFLY B-D 21G,2108324,CDM,270,RC,,,outpatient,,,9.84,5.9,,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,8.86,
BUTTERFLY B-D 25,2108321,CDM,270,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
BUTTERFLY MONOJECT 19G,2108325,CDM,270,RC,,,outpatient,,,7.96,4.78,,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,7.16,
CALGON SCRUB SPONGE OPTIPORE,2102012,CDM,270,RC,,,outpatient,,,13.58,8.15,,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,12.22,
CALGON SUR CLENZ 100ML,2102013,CDM,270,RC,,,outpatient,,,30.66,18.4,,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,27.59,
CAST SHOE,2103177,CDM,270,RC,,,outpatient,,,87.1,52.26,,65.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.85,78.39,
CATH CONDUM MED,2100035,CDM,270,RC,,,outpatient,,,34.69,20.81,,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,31.22,
CATH CONDUM SMALL,2109078,CDM,270,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
CATH INTRAUTERINE TIP TRANSDUCER,2102291,CDM,270,RC,,,outpatient,,,278.28,166.97,,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,175.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,250.45,
CATH LEG STRAP,2100441,CDM,270,RC,,,outpatient,,,15.3,9.18,,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,13.77,
CHLOROPREP 3ML*,2112326,CDM,270,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
CHLOROPREP ORANGE*,2109716,CDM,270,RC,,,outpatient,,,133.9,80.34,,100.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.44,120.51,
CIRCON LAP/ENDO SMOKE EVAC KT REFBLAP100,2108877,CDM,270,RC,,,outpatient,,,179.61,107.77,,134.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.8,161.65,
CLAVICAL BRACE MEDIUM,2102386,CDM,270,RC,,,outpatient,,,84.95,50.97,,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,76.46,
CLAVICAL BRACE X-SMALL79-85002,2108681,CDM,270,RC,,,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,65.64,
CLAVICLE BRACE LG,2100264,CDM,270,RC,,,outpatient,,,145.05,87.03,,108.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,91.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.72,130.55,
CLAVICLE BRACE MED,2100263,CDM,270,RC,,,outpatient,,,136.33,81.8,,102.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.93,122.7,
CLAVICLE BRACE XLG,2102084,CDM,270,RC,,,outpatient,,,98.9,59.34,,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.26,89.01,
CO2 ORAL NASAL SAMPLING TUBING 010433,2112628,CDM,270,RC,,,outpatient,,,81.13,48.68,,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.62,73.02,
CO2 ORAL SAMPLING LINE& ADAPTER,2113067,CDM,270,RC,,,outpatient,,,49.6,29.76,,37.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.16,44.64,
COBAN BANDAGE 3IN*,2100624,CDM,270,RC,,,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,25.82,
COBAN BANDAGE 4IN*,2100625,CDM,270,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
COBAN BANDAGE 6IN*,2100626,CDM,270,RC,,,outpatient,,,55.19,33.11,,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.31,49.67,
COLLAR NO NECK,2102168,CDM,270,RC,,,outpatient,,,169.37,101.62,,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,106.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.7,152.43,
COLLAR NO NECK 2202123,2102167,CDM,270,RC,,,outpatient,,,166.91,100.15,,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,150.22,
COLLAR NO NECK BABY 4990833,2102340,CDM,270,RC,,,outpatient,,,155.17,93.1,,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.79,139.65,
COLLAR NO NECK PED,2102164,CDM,270,RC,,,outpatient,,,185.49,111.29,,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,166.94,
COLLAR NO NECK SHORT,2102166,CDM,270,RC,,,outpatient,,,185.49,111.29,,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,166.94,
COMB/BRUSH SET INFANT,2112182,CDM,270,RC,,,outpatient,,,3.28,1.97,,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,2.95,
CONMED ACCESSORY ELECTRODE,2108470,CDM,270,RC,,,outpatient,,,10.51,6.31,,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,9.46,
CONMED DEFIB ADULT,2112553,CDM,270,RC,,,outpatient,,,43.26,25.96,,32.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,38.93,
CONMED DEFIB PED,2112554,CDM,270,RC,,,outpatient,,,146.15,87.69,,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.95,131.54,
CPM PAD 5315-0117,2110399,CDM,270,RC,,,outpatient,,,200.52,120.31,,150.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.09,180.47,
CYTOLOGY BRUSHES DISP,2108484,CDM,270,RC,,,outpatient,,,141.23,84.74,,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,127.11,
DEFIB PAD PHYSIO CONTROL,2102439,CDM,270,RC,,,outpatient,,,98.34,59,,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,88.51,
DEFIB PADS,2100652,CDM,270,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
DELIVERY RM PREP,2100400,CDM,270,RC,,,outpatient,,,118.56,71.14,,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.29,106.7,
DEVON ARM STRAPS,2109147,CDM,270,RC,,,outpatient,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,6.63,
DISP. OXYGEN MASK,2600041,CDM,270,RC,,,outpatient,,,11.03,6.62,,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.26,9.93,
DISP. VENTI MASK,2600042,CDM,270,RC,,,outpatient,,,12.31,7.39,,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,11.08,
DRAINAGE BAG MDD600,2112322,CDM,270,RC,,,outpatient,,,44.53,26.72,,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,40.08,
EAR SYRINGE 1 OZ,2101340,CDM,270,RC,,,outpatient,,,49.73,29.84,,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,44.76,
ELASTIKON 2 inch,2101371,CDM,270,RC,,,outpatient,,,17.82,10.69,,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.65,16.04,
ELASTIKON 3 inch,2101372,CDM,270,RC,,,outpatient,,,37.77,22.66,,28.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.74,33.99,
ELASTIKON 4 inch,2101370,CDM,270,RC,,,outpatient,,,56,33.6,,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,50.4,
ELECTRODE BLUE SENSOR PED SPOOS,2109145,CDM,270,RC,,,outpatient,,,1.8,1.08,,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.37,1.62,
ELECTRODE PACING ADULT ZOLL,2101959,CDM,270,RC,,,outpatient,,,490.98,294.59,,368.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,368.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.6,441.88,
ELECTRODE PACING PED ZOLL,2101960,CDM,270,RC,,,outpatient,,,474.33,284.6,,355.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,355.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,355.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,298.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.19,426.9,
ELECTRODE PED. (ARBO),2102199,CDM,270,RC,,,outpatient,,,15.27,9.16,,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,13.74,
ENDO TUBE 4.0 12-100382040 (NURSERY),2100203,CDM,270,RC,,,outpatient,,,37.15,22.29,,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,33.44,
ENDO TUBE 4.0 SOURCE MARK,2112623,CDM,270,RC,,,outpatient,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,36.88,
ENDO TUBE 5.0,2100204,CDM,270,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
ENDO TUBE 6.0 SOURCE MARK,2100205,CDM,270,RC,,,outpatient,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,36.88,
ENDO TUBE 8.5,2100209,CDM,270,RC,,,outpatient,,,46.99,28.19,,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.63,42.29,
ENDO TUBE 9.0,2100210,CDM,270,RC,,,outpatient,,,21.75,13.05,,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,19.58,
ENDO TUBE 9.0 SOURCE MARK,2112624,CDM,270,RC,,,outpatient,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,36.88,
ENDOTRACHEAL TUBE,2600037,CDM,270,RC,,,outpatient,,,36.34,21.8,,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,32.71,
ENFAMIL BABY BOTTLE 8OZ,2108406,CDM,270,RC,,,outpatient,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,15.25,
ESMARK BANDADE 4X9*,2101330,CDM,270,RC,,,outpatient,,,24.85,14.91,,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,22.37,
ESMARK BANDAGE 6 inch*,2109860,CDM,270,RC,,,outpatient,,,10.3,6.18,,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,9.27,
ESOPHAGEAL STET 18F ES-400-18,2111597,CDM,270,RC,,,outpatient,,,27.59,16.55,,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,24.83,
ET HOLDER ADULT,2108388,CDM,270,RC,,,outpatient,,,40.74,24.44,,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,36.67,
ET HOLDER CHILD,2108387,CDM,270,RC,,,outpatient,,,40.74,24.44,,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,36.67,
ET TUBE CHANGER,2111791,CDM,270,RC,,,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,39.83,
ETHICON ECS29,2100973,CDM,270,RC,,,outpatient,,,1902.44,1141.46,,1426.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1521.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,405.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1426.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1712.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1426.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1426.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1426.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1426.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,389.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1198.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,389.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,389.81,1712.2,
EVACCUM BOTTLE,1400973,CDM,270,RC,,,outpatient,,,14.42,8.65,,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,12.98,
EWALD TUBE 8OZ,2103379,CDM,270,RC,,,outpatient,,,542.26,325.36,,406.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,406.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,406.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.11,488.03,
EWALD TUBE COMPLETE DISP,2102812,CDM,270,RC,,,outpatient,,,401.02,240.61,,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,252.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.17,360.92,
EXERGEN SKIN TEMP SCANNER,2810021,CDM,270,RC,,,outpatient,,,74.58,44.75,,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.28,67.12,
EYE SHIELD W/ GARTER E5691-A-50,2108889,CDM,270,RC,,,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
FEEDING TUBE 8F X 15,2101695,CDM,270,RC,,,outpatient,,,18.3,10.98,,13.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,16.47,
FETAL MONITOR STRAPS DISP 140PSB,2100540,CDM,270,RC,,,outpatient,,,49.73,29.84,,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,44.76,
FLEET PREP KIT,2100525,CDM,270,RC,,,outpatient,,,23.44,14.06,,17.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.8,21.1,
FUTURETECH SENSOR,2103215,CDM,270,RC,,,outpatient,,,30.87,18.52,,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,27.78,
GASTROSTOMY TUBE 22FR*,2101183,CDM,270,RC,,,outpatient,,,434.36,260.62,,325.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,325.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,325.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,273.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89,390.92,
GIGLI SAW BLADE 20I SAW BLADE 20,2101709,CDM,270,RC,,,outpatient,,,84.77,50.86,,63.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.37,76.29,
GLIDESCOPE BFLEX,2113191,CDM,270,RC,,,outpatient,,,550.61,330.37,,412.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,440.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,412.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,412.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,346.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.82,495.55,
GORTEX SUTURE OUO1A,2103273,CDM,270,RC,,,outpatient,,,143.43,86.06,,107.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.39,129.09,
HAND HELD NEBULIZER,2600057,CDM,270,RC,,,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,23.12,
HAND ORTHOSIS GERIATRIC MED RIGHT,2108637,CDM,270,RC,,,outpatient,,,465.21,279.13,,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,418.69,
HEAD CRADLE*,2108373,CDM,270,RC,,,outpatient,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,13.03,
HEAD IMMB ADULT,2102487,CDM,270,RC,,,outpatient,,,76.49,45.89,,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,68.84,
HEAT &MOISTURE EXCHANGE,2108384,CDM,270,RC,,,outpatient,,,18.14,10.88,,13.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,16.33,
HEEL ELBOW PROTECT,2100259,CDM,270,RC,,,outpatient,,,11.33,6.8,,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,10.2,
HEEL WARMER 114760-010T,2102990,CDM,270,RC,,,outpatient,,,10.65,6.39,,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,9.59,
HEELBO JACKET,2102101,CDM,270,RC,,,outpatient,,,259.5,155.7,,194.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.17,233.55,
HIBICLENS 4OZ,2100543,CDM,270,RC,,,outpatient,,,51.5,30.9,,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,46.35,
HILL RILL ADVANYTA 2 wP500,2108668,CDM,270,RC,,,outpatient,,,82.77,49.66,,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.96,74.49,
HILL ROM ACUCAIR,2108721,CDM,270,RC,,,outpatient,,,53.27,31.96,,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,47.94,
HILL ROM AIR MATTRESS BLOWER,2110774,CDM,270,RC,,,outpatient,,,93.98,56.39,,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,84.58,
HILL ROM BARIATRIC WHEELCHAIR,2110347,CDM,270,RC,,,outpatient,,,144.79,86.87,,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,91.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,130.31,
HILL ROM CLINITRON RITE HITE,2108879,CDM,270,RC,,,outpatient,,,824.46,494.68,,618.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,659.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,618.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,742.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,618.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,618.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,618.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,618.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,519.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.93,742.01,
HILL ROM COMMODE CHAIR,2110348,CDM,270,RC,,,outpatient,,,96.44,57.86,,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,86.8,
HILL ROM EXCEL CARE,2103364,CDM,270,RC,,,outpatient,,,463.04,277.82,,347.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,347.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,347.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,291.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.88,416.74,
HILL ROM TOTAL CARE BARIATRIC BED,2109731,CDM,270,RC,,,outpatient,,,295.59,177.35,,221.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,221.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,186.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.57,266.03,
HILL ROM TRIFLEX II FRAME,2110775,CDM,270,RC,,,outpatient,,,207.08,124.25,,155.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,155.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,130.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.43,186.37,
HILL ROM TRIFLEX II MATTRESS,2111761,CDM,270,RC,,,outpatient,,,139.87,83.92,,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,125.88,
HILL ROM TRIFLEX II MATTRESS,2112026,CDM,270,RC,,,outpatient,,,135.77,81.46,,101.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.82,122.19,
HOPKINS MRSA KIT CHILD,2111408,CDM,270,RC,,,outpatient,,,134.96,80.98,,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.65,121.46,
HOSE KNEE XL REGULAR TED 7604,2112001,CDM,270,RC,,,outpatient,,,60.66,36.4,,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.43,54.59,
HOSE KNEE XXLG 3583007470,2111139,CDM,270,RC,,,outpatient,,,34.97,20.98,,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,31.47,
HOT PACK 6780649,2109513,CDM,270,RC,,,outpatient,,,3.28,1.97,,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,2.95,
ICE BAG,2100404,CDM,270,RC,,,outpatient,,,28.54,17.12,,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.85,25.69,
IMED VALUE ADAPTER 2000E,2102567,CDM,270,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
INFUSION PRESSURE BAG DISP,2101435,CDM,270,RC,,,outpatient,,,150.79,90.47,,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,135.71,
INSPIROMETER INITIAL,2600021,CDM,270,RC,,,outpatient,,,22.66,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,20.39,
INSPIROMETER SUBSEQUENT TX,2600022,CDM,270,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
INT STYLETTE ADULT,2101207,CDM,270,RC,,,outpatient,,,28.33,17,,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,25.5,
INT STYLETTE ADULT SOURCE MARK,2111837,CDM,270,RC,,,outpatient,,,10.3,6.18,,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,9.27,
INVALID RING,2100267,CDM,270,RC,,,outpatient,,,134.68,80.81,,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.6,121.21,
IRRIGATION BLADDER SET,2100410,CDM,270,RC,,,outpatient,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,36.88,
ISOCAL,2108671,CDM,270,RC,,,outpatient,,,15.17,9.1,,11.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.11,13.65,
ISOLATION LINER 2MIL,2108651,CDM,270,RC,,,outpatient,,,29.18,17.51,,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,26.26,
IV PREP KIT,2100380,CDM,270,RC,,,outpatient,,,110.21,66.13,,82.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.58,99.19,
J & J NUBREDE 4X4,2103084,CDM,270,RC,,,outpatient,,,6.47,3.88,,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,5.82,
J & J NUGEL 3 3/4 X 3 3/4,2103082,CDM,270,RC,,,outpatient,,,36.17,21.7,,27.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.41,32.55,
J SPLINT ARM ADULT,2101593,CDM,270,RC,,,outpatient,,,199.7,119.82,,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.92,179.73,
J SPLINT ARM CHILD,2101592,CDM,270,RC,,,outpatient,,,156.54,93.92,,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,98.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.08,140.89,
J SPLINT LEG ADULT,2101595,CDM,270,RC,,,outpatient,,,294.22,176.53,,220.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,220.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,185.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.29,264.8,
J SPLINT LEG CHILD,2101594,CDM,270,RC,,,outpatient,,,284.38,170.63,,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,179.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.27,255.94,
JELCO 14GX2 1/4,2101707,CDM,270,RC,,,outpatient,,,37.15,22.29,,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,33.44,
JELCO 14GX2 4498,2101717,CDM,270,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
JELCO 16GA PROTECTIVE PLUS,2101699,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
JELCO 22GA,2100368,CDM,270,RC,,,outpatient,,,23.02,13.81,,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,20.72,
JELCO METAL HUB 16G 4412,2109617,CDM,270,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
KED RENTAL,2102475,CDM,270,RC,,,outpatient,,,127.31,76.39,,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,114.58,
KIT OB,2102695,CDM,270,RC,,,outpatient,,,147.78,88.67,,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,133,
KNEE BRACE POST OP MED 13 79-80005,2102435,CDM,270,RC,,,outpatient,,,187.14,112.28,,140.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,140.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,117.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.34,168.43,
KNEE BRACE POST OP XLG 12 3841-16,2108718,CDM,270,RC,,,outpatient,,,133.57,80.14,,100.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,120.21,
KNEE COMPRESSION WRAP 1229-GEL-2,2109941,CDM,270,RC,,,outpatient,,,143.96,86.38,,107.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,129.56,
KNEE I PRO ICE PAK PI420,2111512,CDM,270,RC,,,outpatient,,,192.04,115.22,,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,172.84,
KNEE IMM 2XLG 79-80029,2110951,CDM,270,RC,,,outpatient,,,58.2,34.92,,43.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,52.38,
KNEE IMM LG 79-80027,2101339,CDM,270,RC,,,outpatient,,,240.95,144.57,,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,216.86,
KNEE IMM MED 79-80025,2101338,CDM,270,RC,,,outpatient,,,307.88,184.73,,230.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,193.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.08,277.09,
KNEE IMM SM 79-80023,2101337,CDM,270,RC,,,outpatient,,,252.97,151.78,,189.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,189.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,159.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.83,227.67,
KNEE IMM UNIV DJ 79-96882,2109156,CDM,270,RC,,,outpatient,,,149.16,89.5,,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,134.24,
KNEE IMM XLG 79-80028,2101605,CDM,270,RC,,,outpatient,,,149.16,89.5,,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,134.24,
LAP SPONGE 18/18,2100026,CDM,270,RC,,,outpatient,,,18.54,11.12,,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.69,
LAP SPONGE 4/18,2102717,CDM,270,RC,,,outpatient,,,13.79,8.27,,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,12.41,
LEVINE TUBE 16FR,2100566,CDM,270,RC,,,outpatient,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,24.1,
LOTION MEDICHOICE*,2103418,CDM,270,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
LSB W/HEAD BLOCKS RENTAL,2102476,CDM,270,RC,,,outpatient,,,141.42,84.85,,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,89.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,127.28,
MASIMO PED. PULSE OX PROBE,2113193,CDM,270,RC,,,outpatient,,,81.96,49.18,,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,73.76,
MASK #3 TODDLER,2102289,CDM,270,RC,,,outpatient,,,10.38,6.23,,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,9.34,
MASK #4 SM ADULT JV6840,2102036,CDM,270,RC,,,outpatient,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,11.32,
MEDA BOOT,2103088,CDM,270,RC,,,outpatient,,,233.08,139.85,,174.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,146.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.76,209.77,
MEDELA NIPPLE SHIELD REGULAR,2108896,CDM,270,RC,,,outpatient,,,32.51,19.51,,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,29.26,
MEDELA TENDER LAN 87121,2108897,CDM,270,RC,,,outpatient,,,12.3,7.38,,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,11.07,
MEDIPORE DRESSING 5X11*,2109341,CDM,270,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
MEDIPORE DRESSING 5X5*,2109340,CDM,270,RC,,,outpatient,,,2.06,1.24,,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,1.85,
MEDLINE BODY WASH,2103416,CDM,270,RC,,,outpatient,,,15.3,9.18,,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,13.77,
MEDLINE CALAZIME PASTE MSC094524,2109690,CDM,270,RC,,,outpatient,,,44.14,26.48,,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,39.73,
MEDLINE FLAT DRAPE 3/4 DYNJP2416,2102541,CDM,270,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
MITT MESH FINGER CONTROL,2101171,CDM,270,RC,,,outpatient,,,185.49,111.29,,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,166.94,
MONTGOMERY STRAPS,2102544,CDM,270,RC,,,outpatient,,,20.9,12.54,,15.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.28,18.81,
MORGAN LENS,2108961,CDM,270,RC,,,outpatient,,,122.85,73.71,,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.17,110.57,
NASAL CANNULA *,2112105,CDM,270,RC,,,outpatient,,,28.84,17.3,,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,25.96,
NASAL CANNULA 4707F-25SA,2111638,CDM,270,RC,,,outpatient,,,16.23,9.74,,12.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.33,14.61,
NASAL CANNULA 4998458,2109552,CDM,270,RC,,,outpatient,,,3.5,2.1,,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,3.15,
NASAL CANNULA 77-4706F-10,2109216,CDM,270,RC,,,outpatient,,,28.86,17.32,,21.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,25.97,
NASAL CANNULA ADULT 1820*,2103329,CDM,270,RC,,,outpatient,,,5.15,3.09,,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.64,
NASOPHARYNGEAL AIR 28F 7.0,2101526,CDM,270,RC,,,outpatient,,,38.24,22.94,,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,34.42,
NASOPHARYNGEAL AIR 30F 7.5*,2100482,CDM,270,RC,,,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,26.8,
NF-HYDROCORTISONE 10% CREAM,1402077,CDM,270,RC,,,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
NON REBREATHER 4996737,2109578,CDM,270,RC,,,outpatient,,,7.32,4.39,,5.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.5,6.59,
O2 SPECIAL AREAS,2600061,CDM,270,RC,,,outpatient,,,121.54,72.92,,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,109.39,
OBAGI ACTION,2109676,CDM,270,RC,,,outpatient,,,55.17,33.1,,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,49.65,
OBAGI BLENDER,2109686,CDM,270,RC,,,outpatient,,,84.55,50.73,,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,76.1,
OBAGI C CLARIFYING SERUM,2109679,CDM,270,RC,,,outpatient,,,94.84,56.9,,71.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.43,85.36,
OBAGI C CLEANSING GEL,2109678,CDM,270,RC,,,outpatient,,,50.71,30.43,,38.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.39,45.64,
OBAGI C EXFOLIATING DAY LOTION,2109680,CDM,270,RC,,,outpatient,,,65.46,39.28,,49.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.41,58.91,
OBAGI C SUN GUARD,2109682,CDM,270,RC,,,outpatient,,,56.65,33.99,,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,50.99,
OBAGI C THERAPY NIGHT CREAM,2109681,CDM,270,RC,,,outpatient,,,87.53,52.52,,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.93,78.78,
OBAGI CLEAR,2109684,CDM,270,RC,,,outpatient,,,87.53,52.52,,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.93,78.78,
OBAGI EXFADERM,2109685,CDM,270,RC,,,outpatient,,,69.17,41.5,,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.17,62.25,
OBAGI EXFODERM FORTA,2109674,CDM,270,RC,,,outpatient,,,69.17,41.5,,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.17,62.25,
OBAGI FOAMING GEL,2109673,CDM,270,RC,,,outpatient,,,52.94,31.76,,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,47.65,
OBAGI GENTLE CLEANSER 7006,2109672,CDM,270,RC,,,outpatient,,,52.94,31.76,,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,47.65,
OBAGI PROTECTION,2109675,CDM,270,RC,,,outpatient,,,57.39,34.43,,43.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,51.65,
OBAGI SUNFADER,2109687,CDM,270,RC,,,outpatient,,,72.14,43.28,,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,64.93,
OBAGI TONER,2109677,CDM,270,RC,,,outpatient,,,52.94,31.76,,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.85,47.65,
OBAGI TRETINOIN CREAM,2109688,CDM,270,RC,,,outpatient,,,84.55,50.73,,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.32,76.1,
OSTOMY FIRST CHOICE CUT TO FIT POUCH W/W,2103448,CDM,270,RC,,,outpatient,,,50.26,30.16,,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,45.23,
OXYGEN - VENT,2600096,CDM,270,RC,,,outpatient,,,40.17,24.1,,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.15,
OXYGEN CANNULA,2600043,CDM,270,RC,,,outpatient,,,9.56,5.74,,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
OXYGEN EXT TUBING,2600044,CDM,270,RC,,,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.54,
OXYGEN INSTALLATION,2600009,CDM,270,RC,,,outpatient,,,30.9,18.54,,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,27.81,
OXYGEN PER HOUR ANY MODALITY,2600011,CDM,270,RC,,,outpatient,,,2.06,1.24,,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,1.85,
OXYHOOD,2600052,CDM,270,RC,,,outpatient,,,10.65,6.39,,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,9.59,
OXYHOOD SETUP,2600003,CDM,270,RC,,,outpatient,,,54.1,32.46,,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,48.69,
PACK CYSTO PACK DYNJP5010,2111868,CDM,270,RC,,,outpatient,,,32.24,19.34,,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.61,29.02,
PACK LAP 88088,2101406,CDM,270,RC,,,outpatient,,,251.33,150.8,,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.5,226.2,
PACK LITHOTOMY DYNJP9010,2108660,CDM,270,RC,,,outpatient,,,63.38,38.03,,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,57.04,
PACK MINOR MEDLINE DYNJS0104,2108954,CDM,270,RC,,,outpatient,,,963.05,577.83,,722.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,770.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,722.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,722.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,606.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.33,866.75,
PACK OB,2100282,CDM,270,RC,,,outpatient,,,301.32,180.79,,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,271.19,
PEAK FLOWMETER,2103301,CDM,270,RC,,,outpatient,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,124.42,
PEDIPACK RENTAL,2102484,CDM,270,RC,,,outpatient,,,141.42,84.85,,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,89.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,127.28,
PERINEAL COLD PACK MDS138055,2100533,CDM,270,RC,,,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.54,
PHISODERM BABY WASH 8 OZ HEAD TO TOE,2112183,CDM,270,RC,,,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,26.8,
PHY CON QUIK COMBO ADULT 11996-000017,2112052,CDM,270,RC,,,outpatient,,,133.78,80.27,,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,120.4,
PHY CON QUIK COMBO PED 11996-000093,2112053,CDM,270,RC,,,outpatient,,,152.71,91.63,,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,137.44,
POST OP SHOE FEMALE LG 79-90197,2109288,CDM,270,RC,,,outpatient,,,52.45,31.47,,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,47.21,
POST OP SHOE FEMALE MED 79-90195,2102447,CDM,270,RC,,,outpatient,,,99.71,59.83,,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,89.74,
POST OP SHOE FEMALE SM 79-90193,2102446,CDM,270,RC,,,outpatient,,,99.71,59.83,,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,89.74,
POST OP SHOE MALE MED 79-90185,2102450,CDM,270,RC,,,outpatient,,,110.92,66.55,,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,99.83,
POST OP SHOE MALE SMALL 79-90183,2109286,CDM,270,RC,,,outpatient,,,52.45,31.47,,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,47.21,
POST OP SHOE MENS LG 79-90187,2102451,CDM,270,RC,,,outpatient,,,110.92,66.55,,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,99.83,
PRECIP PACK,1750026,CDM,270,RC,,,outpatient,,,301.32,180.79,,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,271.19,
PROTECTOR CROUCH CORNEAL,2109139,CDM,270,RC,,,outpatient,,,11.57,6.94,,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,10.41,
PULSE OX PROBE DISP,2103211,CDM,270,RC,,,outpatient,,,81.96,49.18,,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,73.76,
RESISTANCE EXERCISER,2108434,CDM,270,RC,,,outpatient,,,76.17,45.7,,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.61,68.55,
RESUSITATION BAG SET UP,2600045,CDM,270,RC,,,outpatient,,,42.34,25.4,,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,38.11,
ROOM HUMIDIFIER,2600025,CDM,270,RC,,,outpatient,,,34.15,20.49,,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7,30.74,
ROYCE SHOE PRESSURE REFIEF LG,2108635,CDM,270,RC,,,outpatient,,,438.69,263.21,,329.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,329.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,394.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,276.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.89,394.82,
ROYCE SHOE PRESSURE REFIEF MED,2108634,CDM,270,RC,,,outpatient,,,516.44,309.86,,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,325.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.82,464.8,
ROYCE SHOE PRESSURE RELIEF SMALL,2108633,CDM,270,RC,,,outpatient,,,516.44,309.86,,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,325.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.82,464.8,
ROYCE SHOE PRESSURE RELIEF X-LG,2108907,CDM,270,RC,,,outpatient,,,430.73,258.44,,323.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,323.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,323.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,271.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.26,387.66,
RT 0.9% NACL SOLUTION,2103414,CDM,270,RC,,,outpatient,,,4.92,2.95,,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,4.43,
RT 1 LITER STERILE WATER 2D0735X,2103309,CDM,270,RC,,,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,25.82,
RT 1070ML NEB ADAPTER*,2110375,CDM,270,RC,,,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.05,
RT A-LINE KIT,2108385,CDM,270,RC,,,outpatient,,,52.73,31.64,,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,47.46,
RT ABG 23G KIT*,2108386,CDM,270,RC,,,outpatient,,,13.11,7.87,,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,11.8,
RT ABG KIT 25G,2110374,CDM,270,RC,,,outpatient,,,13.11,7.87,,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,11.8,
RT ADULT HME 19912,2110596,CDM,270,RC,,,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,13.91,
RT AEROSOL TUBING W/FACE TENT,2103333,CDM,270,RC,,,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,12.78,
RT AMBU/ADU,2103322,CDM,270,RC,,,outpatient,,,58.71,35.23,,44.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.03,52.84,
RT AMBU/INFANT NEONATE*,2103318,CDM,270,RC,,,outpatient,,,249.41,149.65,,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,157.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.1,224.47,
RT AMBU/PED,2103323,CDM,270,RC,,,outpatient,,,260.89,156.53,,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,164.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.46,234.8,
RT BIPAP CIRCUIT,2110414,CDM,270,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
RT BITE BLOCK 103-11040EA,2112065,CDM,270,RC,,,outpatient,,,1.91,1.15,,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,1.72,
RT CIRCULAINE CIRCUIT,2103316,CDM,270,RC,,,outpatient,,,40.63,24.38,,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,36.57,
RT CIRCULAIRE MASK,2108363,CDM,270,RC,,,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
RT CO2 DETECTOR,2103336,CDM,270,RC,,,outpatient,,,117.47,70.48,,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,105.72,
RT CO2 DETECTOR AMBU*,2111599,CDM,270,RC,,,outpatient,,,35.02,21.01,,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.18,31.52,
RT CO2 DETECTOR PED AMBU,2111675,CDM,270,RC,,,outpatient,,,51.91,31.15,,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,46.72,
RT CPAP LG 73.1018594,2110379,CDM,270,RC,,,outpatient,,,20.6,12.36,,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.54,
RT CPAP MED 73-1018593,2109278,CDM,270,RC,,,outpatient,,,20.6,12.36,,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.54,
RT CPAP SMALL 73-1018592,2110377,CDM,270,RC,,,outpatient,,,69.94,41.96,,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.33,62.95,
RT DALE TRACH TUBE HOLDER*,2102750,CDM,270,RC,,,outpatient,,,32.15,19.29,,24.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.59,28.94,
RT DRAINAGE BAG,2103428,CDM,270,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
RT E-TUBE HOLDER,2108919,CDM,270,RC,,,outpatient,,,27.87,16.72,,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.71,25.08,
RT FACE MASK LG 1061620,2112282,CDM,270,RC,,,outpatient,,,202.16,121.3,,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.42,181.94,
RT FACE MASK NPPV LG 1012638,2112285,CDM,270,RC,,,outpatient,,,119.11,71.47,,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,107.2,
RT FACE MASK NPPV MED 1012637,2112284,CDM,270,RC,,,outpatient,,,119.11,71.47,,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,107.2,
RT FACE MASK NPPV SM 1012636,2112283,CDM,270,RC,,,outpatient,,,119.11,71.47,,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,107.2,
RT FISHERPAYKEL H20 CHAMBER MR250,2110574,CDM,270,RC,,,outpatient,,,51.88,31.13,,38.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.63,46.69,
RT HAND HELD NEB BREATH TREATMENT*,2103335,CDM,270,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
RT HEATED BIPAP CIRCUIT,2113218,CDM,270,RC,,,outpatient,,,266.35,159.81,,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,167.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,239.72,
RT HEATED BREATHING TUBE&CHAMBER KIT,2113197,CDM,270,RC,,,outpatient,,,132.61,79.57,,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.17,119.35,
RT HUDSON PRESSURE LINE ADAPTER 1642,2112639,CDM,270,RC,,,outpatient,,,11.21,6.73,,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,10.09,
RT HUM 500ML DISP*,2103337,CDM,270,RC,,,outpatient,,,6.18,3.71,,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,5.56,
RT HUMIDIFICATION CHAMBER,2113219,CDM,270,RC,,,outpatient,,,266.35,159.81,,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,167.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.58,239.72,
RT HUMIDIFIER ADAPTER,2108414,CDM,270,RC,,,outpatient,,,5.3,3.18,,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,4.77,
RT HUMIDIFIER W/O ADAPTER,2103369,CDM,270,RC,,,outpatient,,,14.33,8.6,,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,12.9,
RT HUMIFIFIER DISP,2103326,CDM,270,RC,,,outpatient,,,11.57,6.94,,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,10.41,
RT INS CIRC 001903A,2103338,CDM,270,RC,,,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,13.91,
RT INSPIROMETER 5000,2103321,CDM,270,RC,,,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,13.91,
RT IPPB CIRCUIT,2103319,CDM,270,RC,,,outpatient,,,13.47,8.08,,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.76,12.12,
RT MARPAC ET TAPE 304B,2108775,CDM,270,RC,,,outpatient,,,5.15,3.09,,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.64,
RT MDI FOR VENT,2108361,CDM,270,RC,,,outpatient,,,43.18,25.91,,32.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.85,38.86,
RT NASAL CANNULA ADULT 25*,2103393,CDM,270,RC,,,outpatient,,,43.71,26.23,,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,39.34,
RT NON REBREATHER MASK PED 01058,2103339,CDM,270,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
RT NOSE CLIPS,2111231,CDM,270,RC,,,outpatient,,,1.91,1.15,,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.39,1.72,
RT O2 NON REBREATHER MASK ADULT,2103327,CDM,270,RC,,,outpatient,,,5.15,3.09,,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.64,
RT OPTIFLOW MEDIUM NASAL CANN.,2113200,CDM,270,RC,,,outpatient,,,244.22,146.53,,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,153.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.04,219.8,
RT OPTIFLOW SMALL NASAL CANN.,2113199,CDM,270,RC,,,outpatient,,,244.22,146.53,,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,153.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.04,219.8,
RT OXY-EARS 1303,2111019,CDM,270,RC,,,outpatient,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.17,
RT PALM CUP MED,2103341,CDM,270,RC,,,outpatient,,,36.71,22.03,,27.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.52,33.04,
RT PALM CUP NEONATAL,2103306,CDM,270,RC,,,outpatient,,,33.05,19.83,,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.77,29.75,
RT PALM CUP PE,2103307,CDM,270,RC,,,outpatient,,,37.97,22.78,,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,34.17,
RT PED AEROSOL MASK,2103368,CDM,270,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
RT PEEP VALVE,2103317,CDM,270,RC,,,outpatient,,,62.01,37.21,,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,55.81,
RT PERCUSSOR PALM 63MM,2113042,CDM,270,RC,,,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,23.12,
RT PERCUSSOR PALM LG,2103308,CDM,270,RC,,,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,39.83,
RT PULSE OX PROBE CHILD S543-1270,2103212,CDM,270,RC,,,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,132.28,
RT SPU VENT FILTER*,2110565,CDM,270,RC,,,outpatient,,,44.29,26.57,,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,39.86,
RT THERA PEP CIRCUIT,2103305,CDM,270,RC,,,outpatient,,,110.33,66.2,,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,99.3,
RT TRAC WET PACK 14FR 22056,2103310,CDM,270,RC,,,outpatient,,,47.38,28.43,,35.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.71,42.64,
RT TRACH FLEX CONNECTOR 3222,2110822,CDM,270,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
RT TRACH STRAP,2108360,CDM,270,RC,,,outpatient,,,22.81,13.69,,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.53,
RT TRACH TUBE HOLDER INFANT,2108918,CDM,270,RC,,,outpatient,,,20.76,12.46,,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,18.68,
RT TRANSFER SET 2C7103,2103342,CDM,270,RC,,,outpatient,,,21.64,12.98,,16.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,19.48,
RT VENT CIR 001793,2103325,CDM,270,RC,,,outpatient,,,135.96,81.58,,101.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.86,122.36,
RT VENT CIR AIR LIFE 003764,2112650,CDM,270,RC,,,outpatient,,,18.35,11.01,,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,16.52,
RT VENTI MASK DISP,2103328,CDM,270,RC,,,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,6.49,
RT VENTI MASK PED 1096,2103340,CDM,270,RC,,,outpatient,,,30.06,18.04,,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,27.05,
RUBBER BITE LINERS,2103349,CDM,270,RC,,,outpatient,,,86.04,51.62,,64.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.63,77.44,
SCD KNEE LG 9789*,2110338,CDM,270,RC,,,outpatient,,,382.18,229.31,,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.31,343.96,
SCD KNEE MED 9529*,2112504,CDM,270,RC,,,outpatient,,,225.57,135.34,,169.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.22,203.01,
SCD KNEE REGULAR 26 CALF SLEEVE ONLY,2109271,CDM,270,RC,,,outpatient,,,98.03,58.82,,73.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.09,88.23,
SCD KNEE SMALL 9545,2112503,CDM,270,RC,,,outpatient,,,338.64,203.18,,253.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,253.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,253.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,213.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.39,304.78,
SCD KNEE XLG 9790,2111446,CDM,270,RC,,,outpatient,,,382.18,229.31,,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.31,343.96,
SCD MED THIGH 5330 SLEEVE ONLY,2109264,CDM,270,RC,,,outpatient,,,278.28,166.97,,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,175.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,250.45,
SCD THIGH LG TEARAWAY 9780T,2110719,CDM,270,RC,,,outpatient,,,127.31,76.39,,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,114.58,
SCD THIGH SM 9545*,2110486,CDM,270,RC,,,outpatient,,,381.09,228.65,,285.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,285.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,285.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.09,342.98,
SET UP COVER PREFFERED MEDICAL,2108725,CDM,270,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
SEX CRIME KIT,2100550,CDM,270,RC,,,outpatient,,,198.34,119,,148.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,124.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.64,178.51,
SHEET LAP DRAPE TRANSVERSE 29421,2108557,CDM,270,RC,,,outpatient,,,29.87,17.92,,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.12,26.88,
SHEET LAPORATOMY W/ POUCHES*,2102324,CDM,270,RC,,,outpatient,,,28.84,17.3,,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,25.96,
SHOULDER BRACE PADDED CLAV. MED.,2101644,CDM,270,RC,,,outpatient,,,108.31,64.99,,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,68.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.19,97.48,
SHOULDER BRACE PADDED CLAV. SM.,2101645,CDM,270,RC,,,outpatient,,,108.31,64.99,,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,68.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.19,97.48,
SHOULDER COMPRESSION WRAP 2702-GEL-2,2110742,CDM,270,RC,,,outpatient,,,136.59,81.95,,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,122.93,
SHOULDER I PRO ICE PAK PI260,2111514,CDM,270,RC,,,outpatient,,,167.84,100.7,,125.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.39,151.06,
SILVA SORB GEL MSC9301H,2109717,CDM,270,RC,,,outpatient,,,65.67,39.4,,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,59.1,
SILVER SULFADIAZINE (SILVADENE)1%CR 50GM,1400558,CDM,270,RC,,,outpatient,,,43.71,26.23,,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,39.34,
SMART DEFIB PADS II 989803139261,2110283,CDM,270,RC,,,outpatient,,,115.32,69.19,,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.63,103.79,
SODIUM CHLORIDE FOR IRRIGATION 500ML,1404680,CDM,270,RC,,,outpatient,,,14.06,8.44,,10.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,12.65,
SPACE LAB SKIN TEMP PROBE,2102974,CDM,270,RC,,,outpatient,,,77.04,46.22,,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.79,69.34,
SPLINT CLAVICLE CHILD PAD 3403-30,2101642,CDM,270,RC,,,outpatient,,,94.2,56.52,,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.3,84.78,
SPLINT COLLES INF LF 4000-12,2102299,CDM,270,RC,,,outpatient,,,124.97,74.98,,93.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.61,112.47,
SPLINT DOYLE,2103386,CDM,270,RC,,,outpatient,,,246.03,147.62,,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,221.43,
SPLINT EASTON COCKUP LG 4008-14,2101671,CDM,270,RC,,,outpatient,,,126.57,75.94,,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,113.91,
SPLINT EASTON COCKUP MD 4008-12,2101670,CDM,270,RC,,,outpatient,,,126.57,75.94,,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,113.91,
SPLINT EASTON COCKUP SM 4008-12,2101669,CDM,270,RC,,,outpatient,,,126.57,75.94,,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,113.91,
SPLINT FABRICATION MATERIALS COMPLEX,2800089,CDM,270,RC,,,outpatient,,,120.48,72.29,,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,108.43,
SPLINT FABRICATION MATERIALS INTERMEDIAT,2800088,CDM,270,RC,,,outpatient,,,83.59,50.15,,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.13,75.23,
SPLINT FABRICATION MATERIALS SIMPLE,2800087,CDM,270,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
SPLINT FOREARM SM R,2101678,CDM,270,RC,,,outpatient,,,110.44,66.26,,82.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.63,99.4,
SPLINT HAND M-R 4004-10,2101665,CDM,270,RC,,,outpatient,,,302.04,181.22,,226.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,190.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.89,271.84,
SPLINT HUMERAL L 37-2163-000,2112665,CDM,270,RC,L3980,HCPCS,outpatient,,,804.8,482.88,,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,643.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,507.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.9,724.32,
SPLINT HUMERAL XL 37-2164-000,2112664,CDM,270,RC,L3980,HCPCS,outpatient,,,804.8,482.88,,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,643.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,507.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.9,724.32,
SPLINT LEG SMALL,2108655,CDM,270,RC,,,outpatient,,,445.48,267.29,,334.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,356.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,334.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,334.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,280.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.28,400.93,
SPLINT NASAL 4121-00,2101734,CDM,270,RC,,,outpatient,,,52.2,31.32,,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.7,46.98,
"SPLINT OCL 2,3,4 SHORT ARM",2101588,CDM,270,RC,,,outpatient,,,113.41,68.05,,85.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.24,102.07,
SPLINT THUMB SPICA RIGHT UNIVERSAL,2112738,CDM,270,RC,,,outpatient,,,59.55,35.73,,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,53.6,
STERILE WATER FOR INJ 50ML VIAL,5208,CDM,270,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
STERILE WATER FOR IRRIGATION,1403808,CDM,270,RC,,,outpatient,,,45.35,27.21,,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,40.82,
STETHESCOPE DISP.,2100375,CDM,270,RC,,,outpatient,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,24.59,
STPLR DGIA 80 RELOADER 031739L,2102635,CDM,270,RC,,,outpatient,,,426.38,255.83,,319.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,319.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,268.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.37,383.74,
STYLETTE LIGHTED INTUBATING PED 9021002,2102752,CDM,270,RC,,,outpatient,,,198.6,119.16,,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,178.74,
SURGICAL DRESS 4X6***,2100001,CDM,270,RC,,,outpatient,,,11.74,7.04,,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,10.57,
SURGICAL DRESS 8x6***,2100002,CDM,270,RC,,,outpatient,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,3.93,
SUSPENSORY LARGE,2100372,CDM,270,RC,,,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.11,97.11,
SUSPENSORY MEDIUM,2100373,CDM,270,RC,,,outpatient,,,98.07,58.84,,73.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.09,88.26,
SUSPENSORY SMALL,2100374,CDM,270,RC,,,outpatient,,,80.59,48.35,,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,72.53,
SUSPENSORY XL,2101736,CDM,270,RC,,,outpatient,,,55.46,33.28,,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,49.91,
SUTURE J260H 0 CO VIC*,2101813,CDM,270,RC,,,outpatient,,,205.71,123.43,,154.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.15,185.14,
SYR BD INSULIN LODOSE 28G 1/2CC 1/2 NEED,2108689,CDM,270,RC,,,outpatient,,,53.54,32.12,,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,48.19,
TELFA 3X8,2108912,CDM,270,RC,,,outpatient,,,1.37,0.82,,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,1.23,
TENDERFIX CLOTH TAPE 6X6,2101552,CDM,270,RC,,,outpatient,,,9.76,5.86,,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2,8.78,
THUMB SPICA WRIST SPLINT 11473,2112218,CDM,270,RC,,,outpatient,,,69.28,41.57,,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,62.35,
TONSIL SPONGE (MED STERILE),2101373,CDM,270,RC,,,outpatient,,,63.65,38.19,,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,57.29,
TRACTION SPLINT,2102482,CDM,270,RC,,,outpatient,,,26.74,16.04,,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,24.07,
TRAV EXTENSION 2N8378,2102563,CDM,270,RC,,,outpatient,,,23.76,14.26,,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,21.38,
TRAY ER TRAC,2108727,CDM,270,RC,,,outpatient,,,184.17,110.5,,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.74,165.75,
TRAY UMBILICAL,2100509,CDM,270,RC,,,outpatient,,,78.14,46.88,,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,70.33,
TRAY VAGINAL SPECULUM,2100417,CDM,270,RC,,,outpatient,,,71.18,42.71,,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.58,64.06,
TRIANGLE BANDAGE,2109579,CDM,270,RC,,,outpatient,,,3.29,1.97,,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,2.96,
TRISTATE LANASEPTIC SKIN PROT. LSP0305,2108969,CDM,270,RC,,,outpatient,,,7.43,4.46,,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.52,6.69,
TUBEGAUZE #1,2100465,CDM,270,RC,,,outpatient,,,22.95,13.77,,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.66,
TUBEGAUZE #10,2100609,CDM,270,RC,,,outpatient,,,62.01,37.21,,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,55.81,
TUBEGAUZE #11,2101584,CDM,270,RC,,,outpatient,,,64.82,38.89,,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,58.34,
TUBEGAUZE #2,2100466,CDM,270,RC,,,outpatient,,,18.85,11.31,,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,16.97,
TUBEGAUZE #3,2100500,CDM,270,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
TUBEGAUZE #4,2100501,CDM,270,RC,,,outpatient,,,15.57,9.34,,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,14.01,
TUBEGAUZE #5,2100467,CDM,270,RC,,,outpatient,,,23.23,13.94,,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.91,
TUBEGAUZE #6,2101582,CDM,270,RC,,,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
TUBEGAUZE #7,2100468,CDM,270,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
TUBEGAUZE #8,2100469,CDM,270,RC,,,outpatient,,,37.71,22.63,,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,33.94,
TUBEGAUZE #9,2101583,CDM,270,RC,,,outpatient,,,45.35,27.21,,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,40.82,
UNIVERSAL SLING & S. ONE SIZE FITS ALL,2102414,CDM,270,RC,,,outpatient,,,128.67,77.2,,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,115.8,
UTERINE CURETTE 12MM,2102625,CDM,270,RC,,,outpatient,,,58.46,35.08,,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,52.61,
VASELINE GAUZE 1/2X72,2100366,CDM,270,RC,,,outpatient,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,15.25,
VASELINE GAUZE 1/36,2100010,CDM,270,RC,,,outpatient,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,11.32,
VENOCATH 16,2100627,CDM,270,RC,,,outpatient,,,29.23,17.54,,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,26.31,
VENT ORAL CARE KIT HALYARD,2112829,CDM,270,RC,,,outpatient,,,40.17,24.1,,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.15,
VENTILATOR CIRCUIT,2600036,CDM,270,RC,,,outpatient,,,20.6,12.36,,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.54,
VIAGUARD,2102585,CDM,270,RC,,,outpatient,,,108.18,64.91,,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,68.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,97.36,
VINYL CONNECTING TUBE CTU 14.0-30-ST,2112323,CDM,270,RC,,,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,49.42,
VOLUFEED 180,2102191,CDM,270,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
WAFFLE CUSHION,2103192,CDM,270,RC,,,outpatient,,,165.82,99.49,,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,104.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.98,149.24,
WRIST ANKLE RESTRNT,2100257,CDM,270,RC,,,outpatient,,,53.79,32.27,,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.02,48.41,
WRIST SPLINT UNIVERSAL LEFT 2270806,2108350,CDM,270,RC,,,outpatient,,,96.64,57.98,,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,86.98,
WRIST SPLINT UNIVERSAL LEFT/RIGHT 11406-,2111720,CDM,270,RC,,,outpatient,,,53.56,32.14,,40.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,48.2,
WRIST SPLINT UNIVERSAL RIGHT 2270816,2108351,CDM,270,RC,,,outpatient,,,96.64,57.98,,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,86.98,
YANKUAR SUCTION INST*,2100614,CDM,270,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
ABBOCATH 26G 4535-47,2112438,CDM,272,RC,,,outpatient,,,25.68,15.41,,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,23.11,
ABBOTT EPIDURAL ADMIN.,2103118,CDM,272,RC,,,outpatient,,,142.06,85.24,,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,89.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.11,127.85,
ABD PADS 8/10,2100013,CDM,272,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
ACETIC ACID 0.25% IRR1000ML,2111353,CDM,272,RC,,,outpatient,,,14.85,8.91,,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,13.37,
ACMI PLEATMAN SACK 004942-901,2111345,CDM,272,RC,,,outpatient,,,388.19,232.91,,291.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,291.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,291.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,244.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.54,349.37,
ACU-PUNCH 2MM,2102664,CDM,272,RC,,,outpatient,,,23.24,13.94,,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.92,
ACU-PUNCH 3MM,2102663,CDM,272,RC,,,outpatient,,,23.24,13.94,,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.92,
ACU-PUNCH 4MM,2108909,CDM,272,RC,,,outpatient,,,16.55,9.93,,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,14.9,
ACU-PUNCH 6MM,2109304,CDM,272,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
ADAPTIC DRESS 3X3,2100346,CDM,272,RC,,,outpatient,,,8.2,4.92,,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,7.38,
ADAPTIC DRESS 3X8,2102849,CDM,272,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
ADV O S DRILL BIT 0201,2111093,CDM,272,RC,,,outpatient,,,2340.45,1404.27,,1755.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1872.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,498.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,498.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1755.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,503.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2106.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1755.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1755.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1755.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1755.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,479.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1474.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,479.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,479.56,2106.41,
ADV O S DRILL BIT GOLD 0209-200,2111000,CDM,272,RC,,,outpatient,,,591.77,355.06,,443.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,473.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,443.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,532.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,443.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,372.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.25,532.59,
ADV O S DRILL BIT GREEN SHORT 0210-100,2111331,CDM,272,RC,,,outpatient,,,459.91,275.95,,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,413.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,289.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.24,413.92,
AIR CAST ANKLE BRACE LEFT,2111740,CDM,272,RC,,,outpatient,,,221.41,132.85,,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.37,199.27,
AIR CAST ANKLE BRACE RIGHT,2111741,CDM,272,RC,,,outpatient,,,221.41,132.85,,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.37,199.27,
AIR WALKER FRAC BOOT LG 79-95417,2102636,CDM,272,RC,,,outpatient,,,236.58,141.95,,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,149.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.48,212.92,
AIR WALKER FRAC BOOT MED 79-95415,2102732,CDM,272,RC,,,outpatient,,,236.58,141.95,,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,149.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.48,212.92,
AIR WALKER FRAC BOOT SMALL 79-95413,2102731,CDM,272,RC,,,outpatient,,,223.01,133.81,,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,140.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,200.71,
AIR WALKER FRAC BOOT X-LG 79-95418,2102733,CDM,272,RC,,,outpatient,,,223.01,133.81,,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,140.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.69,200.71,
AIRWAY DEVICE KING LTS-D S 3 499-5318,2112044,CDM,272,RC,,,outpatient,,,191.07,114.64,,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,171.96,
AIRWAY DEVICE KING LTS-D S 4 499-5319,2112045,CDM,272,RC,,,outpatient,,,191.07,114.64,,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,171.96,
AIRWAY DEVICE KING LTS-D S 5 499-5320,2112046,CDM,272,RC,,,outpatient,,,191.07,114.64,,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,171.96,
ALCON 0.3MM TRANSFORMER I/A,2112765,CDM,272,RC,,,outpatient,,,89.65,53.79,,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,80.69,
ALCON 18G BIPOLAR BRUSH 8065804101,2109534,CDM,272,RC,,,outpatient,,,89.75,53.85,,67.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.39,80.78,
ALCON 2.0 CLEAR CUT BLADE 2.6,2112914,CDM,272,RC,,,outpatient,,,167.74,100.64,,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.37,150.97,
ALCON 2.4 DB SLIT KNIFE 8065-9824-65,2112306,CDM,272,RC,,,outpatient,,,111.18,66.71,,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,100.06,
ALCON 2.6 DB SLIT KNIFE 8065982665,2112911,CDM,272,RC,,,outpatient,,,111.18,66.71,,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,100.06,
ALCON 3.0 CLEAR CUT BLADE,2108866,CDM,272,RC,,,outpatient,,,158.07,94.84,,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,99.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.39,142.26,
ALCON 30 DEGREE ABS,2108845,CDM,272,RC,,,outpatient,,,323.36,194.02,,242.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,242.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,242.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,203.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.26,291.02,
ALCON ANGELED I A TIP 8065751511,2112479,CDM,272,RC,,,outpatient,,,57.92,34.75,,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,52.13,
ALCON ANT. VIT. PROBE,2108844,CDM,272,RC,,,outpatient,,,466.32,279.79,,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.55,419.69,
ALCON ANTERIOR VITRECTOMY PAC W/20G INFU,2109203,CDM,272,RC,,,outpatient,,,280.29,168.17,,210.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,210.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,210.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,176.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.43,252.26,
ALCON AQUALASE,2109308,CDM,272,RC,,,outpatient,,,313.34,188,,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,197.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,282.01,
ALCON ATKINSON RETRO NEEDLE,2108867,CDM,272,RC,,,outpatient,,,47.52,28.51,,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,42.77,
ALCON BSS 15ML 0065-0795-15,2108837,CDM,272,RC,,,outpatient,,,33.88,20.33,,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,30.49,
ALCON BSS 500ML BAG 0065-0800-94,2109309,CDM,272,RC,,,outpatient,,,257.07,154.24,,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,161.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,231.36,
ALCON C PACK AS2101-75,2108884,CDM,272,RC,,,outpatient,,,573.71,344.23,,430.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,430.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,516.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,430.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,361.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.55,516.34,
ALCON CAUTERY 8065004601,2109204,CDM,272,RC,,,outpatient,,,176.75,106.05,,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,111.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,159.08,
ALCON CENT INT 23G VITRECTOMY,2112466,CDM,272,RC,,,outpatient,,,405.16,243.1,,303.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,364.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,303.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,255.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.02,364.64,
ALCON CYSTITIOME REV 25G 8065425120,2108840,CDM,272,RC,,,outpatient,,,32.78,19.67,,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,29.5,
ALCON DUOVISC .55 ML,2108839,CDM,272,RC,,,outpatient,,,251.6,150.96,,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,226.44,
ALCON FMS W/INTREPID ULTRA SL 8065752201,2112480,CDM,272,RC,,,outpatient,,,210.16,126.1,,157.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,157.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,157.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,132.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.06,189.14,
ALCON HYDRODISSECTION CANNULA 27GR,2108841,CDM,272,RC,,,outpatient,,,40.63,24.38,,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,36.57,
ALCON INFINITI U/S FMS 8065741097,2109535,CDM,272,RC,,,outpatient,,,301.32,180.79,,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,271.19,
ALCON KELMAN TIP 8065752066,2112796,CDM,272,RC,,,outpatient,,,131.41,78.85,,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.93,118.27,
ALCON KELMAN TIP 8065790023,2108887,CDM,272,RC,,,outpatient,,,517.4,310.44,,388.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,388.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,388.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,325.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.02,465.66,
ALCON KNIFE ANGLED SLIT 30MM 9065993047,2109159,CDM,272,RC,,,outpatient,,,204.89,122.93,,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.98,184.4,
ALCON MICROSPONGE 8065100003,2109323,CDM,272,RC,,,outpatient,,,13.05,7.83,,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,11.75,
ALCON PROSHIELD 24 HOUR,2108843,CDM,272,RC,,,outpatient,,,256.1,153.66,,192.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,192.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,161.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.47,230.49,
ALCON SATIN CRESCENT ANGLED BEVEL,2108868,CDM,272,RC,,,outpatient,,,104.63,62.78,,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.44,94.17,
ALCON SUTURE 10.0 AU-5 8065-692101,2109104,CDM,272,RC,,,outpatient,,,212.26,127.36,,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,133.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.49,191.03,
ALCON TOTAL PLUS VITRECTOMY PAK,2109709,CDM,272,RC,,,outpatient,,,759.72,455.83,,569.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,607.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,161.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,569.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,683.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,569.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,478.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.67,683.75,
ALCON TURBO SONIC MICRO TIP 8065750159,2112478,CDM,272,RC,,,outpatient,,,90.69,54.41,,68.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.58,81.62,
ALCON WIPE INSTRUMENT 8065913195,2109324,CDM,272,RC,,,outpatient,,,321.54,192.92,,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,202.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.88,289.39,
ALLDRESS 6X6,2103035,CDM,272,RC,,,outpatient,,,32.04,19.22,,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.56,28.84,
ALLOGRAFT AMNIOTIC MEMBRANE AD-5230,2111116,CDM,272,RC,,,outpatient,,,1193.62,716.17,,895.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,954.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,895.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1074.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,895.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,895.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,751.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.57,1074.26,
AMNIHOOK,2100284,CDM,272,RC,,,outpatient,,,18.67,11.2,,14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.83,16.8,
ANCHOR MAYO NEEDLE 1824-5DC,2111783,CDM,272,RC,,,outpatient,,,10.39,6.23,,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,9.35,
ANDERSON TUBE AN10,2100073,CDM,272,RC,,,outpatient,,,40.74,24.44,,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,36.67,
ANES 2C9218,2109279,CDM,272,RC,,,outpatient,,,21.58,12.95,,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,19.42,
ANGIO DYN 5F MICRO ACCE,2109424,CDM,272,RC,C1894,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN ANTEGRADE CATH 09900401,2109438,CDM,272,RC,C1751,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN AQUALINER 60000301,2109425,CDM,272,RC,C1769,HCPCS,outpatient,,,294.19,176.51,,220.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,220.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,185.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.28,264.77,
ANGIO DYN BERENSTEIN 10722104,2109426,CDM,272,RC,C1751,HCPCS,outpatient,,,139.72,83.83,,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,125.75,
ANGIO DYN CATH STR ART 10731403,2109644,CDM,272,RC,C1751,HCPCS,outpatient,,,139.72,83.83,,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,125.75,
ANGIO DYN COBRA 65 CATH 10719701,2109497,CDM,272,RC,,,outpatient,,,139.72,83.83,,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,125.75,
ANGIO DYN COBRITA UNO 50723018,2109436,CDM,272,RC,C1751,HCPCS,outpatient,,,161.79,97.07,,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,145.61,
ANGIO DYN DUAL LUMEN PICC 5FR 12102821,2110848,CDM,272,RC,,,outpatient,,,264.8,158.88,,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,238.32,
ANGIO DYN EVENMORE 32CM STR HFS32,2109665,CDM,272,RC,C1750,HCPCS,outpatient,,,695.11,417.07,,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,625.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,437.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,625.6,
ANGIO DYN EVENMORE CATH 14.5 HFS28,2109662,CDM,272,RC,C1750,HCPCS,outpatient,,,695.11,417.07,,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,625.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,437.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,625.6,
ANGIO DYN EVERMORE 36CM STR HFS32,2109667,CDM,272,RC,C1750,HCPCS,outpatient,,,695.11,417.07,,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,625.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,437.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,625.6,
ANGIO DYN FLO 15F X 28CM MR371512,2109525,CDM,272,RC,C1750,HCPCS,outpatient,,,882.67,529.6,,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,706.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,794.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,556.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.86,794.4,
ANGIO DYN FLO CATH 15FX36CM 10301204,2109536,CDM,272,RC,C1750,HCPCS,outpatient,,,668.69,401.21,,501.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,534.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,142.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,501.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,601.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,501.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,421.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.01,601.82,
ANGIO DYN FLOW CATH 15X40 MR371505,2109546,CDM,272,RC,C1750,HCPCS,outpatient,,,1076.92,646.15,,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,861.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,969.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,678.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,969.23,
ANGIO DYN GUIDEWIRE 05500801,2109423,CDM,272,RC,C1769,HCPCS,outpatient,,,103.01,61.81,,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,92.71,
ANGIO DYN GUIDEWIRE ST FIXED 05500802,2109604,CDM,272,RC,C1769,HCPCS,outpatient,,,112.88,67.73,,84.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.13,101.59,
ANGIO DYN KUMPE 10732702,2109428,CDM,272,RC,C1751,HCPCS,outpatient,,,71.62,42.97,,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,64.46,
ANGIO DYN RIM 10733301,2109429,CDM,272,RC,,,outpatient,,,139.72,83.83,,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,125.75,
ANGIO DYN STRAIGHT ART. 10731502,2109427,CDM,272,RC,C1751,HCPCS,outpatient,,,154.47,92.68,,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,139.02,
ANGIO DYN WORKHORSE 16500401,2109430,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN WORKHORSE 16500402,2109431,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN WORKHORSE 16500404,2109432,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN WORKHORSE 16500405,2109704,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN WORKHORSE 16500406,2109433,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN WORKHORSE 16500408,2109434,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN WORKHORSE 16500444,2109435,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN WORKHORSE 5X4X50 16500405,2110591,CDM,272,RC,C1750,HCPCS,outpatient,,,144.5,86.7,,108.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,91.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.61,130.05,
ANGIO DYN WORKHORSE 7X4X50 16500407,2109499,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANGIO DYN WORKHORSE 7X4X75 16500415,2109498,CDM,272,RC,C1725,HCPCS,outpatient,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,297.9,
ANTI REFLUX VALVE,2110802,CDM,272,RC,,,outpatient,,,49.45,29.67,,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,44.51,
APPLIED GEL PORT C8XX2,2111718,CDM,272,RC,,,outpatient,,,1208.15,724.89,,906.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,966.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,257.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,906.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1087.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,906.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,906.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,906.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,906.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,761.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.55,1087.34,
APPLIED MED ART EMB CATH SYNTEL 3 A4F03,2109450,CDM,272,RC,C1757,HCPCS,outpatient,,,270.31,162.19,,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,170.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.39,243.28,
APPLIED MED ART EMB CATH SYNTEL 4 A4F05,2109451,CDM,272,RC,C1757,HCPCS,outpatient,,,270.31,162.19,,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,170.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.39,243.28,
APPLIED MED GRAFT CLEANING KIT A4G02,2109452,CDM,272,RC,,,outpatient,,,246.03,147.62,,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,221.43,
APPLIED MED PYTHON CATH 27FX80CM A4E04,2109527,CDM,272,RC,C1757,HCPCS,outpatient,,,551.67,331,,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,347.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,496.5,
APPLIED MED PYTHON CATH 80 A4E03,2109495,CDM,272,RC,C1757,HCPCS,outpatient,,,551.67,331,,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,347.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,496.5,
APPLIED MED THROM A4558,2109521,CDM,272,RC,C1757,HCPCS,outpatient,,,374.08,224.45,,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,336.67,
APPLIED MED THROMB CATH 3X50 A4535,2109453,CDM,272,RC,C1757,HCPCS,outpatient,,,374.08,224.45,,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,336.67,
APPLIED MED THROMB CATH 4X40 A4544,2109496,CDM,272,RC,C1757,HCPCS,outpatient,,,374.08,224.45,,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,336.67,
APPLIED MED THROMB CATH 4X80 04160A4544,2109504,CDM,272,RC,C1757,HCPCS,outpatient,,,374.08,224.45,,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,336.67,
APPLIED MED THROMB CATH A4545,2109454,CDM,272,RC,C1757,HCPCS,outpatient,,,374.08,224.45,,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,336.67,
APPLIED RETRIEVAL SYSTEM 04160CD001,2110333,CDM,272,RC,,,outpatient,,,505.73,303.44,,379.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,379.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,455.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,379.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,318.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.62,455.16,
APPLIED SLEEVE 5MM C0529,2109773,CDM,272,RC,,,outpatient,,,58.57,35.14,,43.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12,52.71,
APPLIED TRO 10/11 BL less NB11STF(crt33,2109200,CDM,272,RC,,,outpatient,,,251.97,151.18,,188.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.63,226.77,
APPLIED TRO 11MM SLNBFCA11ST(cor71,2111318,CDM,272,RC,,,outpatient,,,141.64,84.98,,106.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,89.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.02,127.48,
APPLIED TROCAR 11MM x100 CTR33,2111317,CDM,272,RC,,,outpatient,,,96.02,57.61,,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,86.42,
APPLIED TROCAR 12X150MM C0R31,2111340,CDM,272,RC,,,outpatient,,,96.02,57.61,,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,86.42,
APPLIED TROCAR 150MM LONG C0641,2102963,CDM,272,RC,,,outpatient,,,342.77,205.66,,257.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,257.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,215.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.23,308.49,
APPLIED TROCAR 5MM BLADELESS CTR03,2109199,CDM,272,RC,,,outpatient,,,208.89,125.33,,156.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,131.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.8,188,
APPLIED TROCAR 5MM CTB03,2102576,CDM,272,RC,,,outpatient,,,1101,660.6,,825.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,234.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,825.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,990.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,825.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,825.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,693.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.59,990.9,
APPLIED TROCAR C0658,2102575,CDM,272,RC,,,outpatient,,,1262.69,757.61,,947.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1010.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,268.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,947.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1136.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,947.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,947.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,947.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,947.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,795.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.73,1136.42,
APPLIED TROCAR Kii BALLOON 12X100 C0R47,2111575,CDM,272,RC,,,outpatient,,,182.47,109.48,,136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.39,164.22,
ARROW ARTERIAL LINE KIT,2109098,CDM,272,RC,,,outpatient,,,144.18,86.51,,108.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.54,129.76,
ARROW DPL (DIAG. PERITONEAL LAVAGE),2100981,CDM,272,RC,,,outpatient,,,351.37,210.82,,263.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,281.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,263.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,316.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,221.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72,316.23,
ARROW EID CATH ONLY,2103043,CDM,272,RC,,,outpatient,,,240.72,144.43,,180.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.32,216.65,
ARROW ES IO 25MM NEEDLE 9001P-VC-005,2112495,CDM,272,RC,,,outpatient,,,320.82,192.49,,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,202.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.74,288.74,
ARROW EZ IO 25MM NEEDLE,2113195,CDM,272,RC,,,outpatient,,,289.84,173.9,,217.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,217.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,217.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.39,260.86,
ARROW EZ IO 45MM NEEDLE 9079P-VC-005,2112496,CDM,272,RC,,,outpatient,,,320.82,192.49,,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,202.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.74,288.74,
ARROW EZ IO STABILIZER 9066-VC-005,2112497,CDM,272,RC,,,outpatient,,,267.88,160.73,,200.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.89,241.09,
ARROW FEMORAL ARTERIAL CATH FA-04020,2109048,CDM,272,RC,,,outpatient,,,96.71,58.03,,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,87.04,
ARROW HI-FLOW FLUID ADMIN SET,2103042,CDM,272,RC,,,outpatient,,,394.97,236.98,,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,248.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,355.47,
ARROW HOWE CVC CT COMPATIBLE,2111384,CDM,272,RC,,,outpatient,,,230.72,138.43,,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,145.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.27,207.65,
ARROW HOWE CVC KIT,2100435,CDM,272,RC,,,outpatient,,,710.28,426.17,,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,639.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,447.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.54,639.25,
ARROW HOWE CVC KIT 16CM,2112443,CDM,272,RC,,,outpatient,,,138.5,83.1,,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,124.65,
ARROW HOWE CVC KIT PED AK-25502,2112448,CDM,272,RC,,,outpatient,,,222.38,133.43,,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,140.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.57,200.14,
ARROW PNEUMOTHOROX KIT,2102590,CDM,272,RC,,,outpatient,,,254.62,152.77,,190.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,190.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,190.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,160.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.17,229.16,
ARROW PSI KIT,2100055,CDM,272,RC,,,outpatient,,,110.01,66.01,,82.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.54,99.01,
ARROW PT65509,2109489,CDM,272,RC,,,outpatient,,,1207.84,724.7,,905.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,966.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,257.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,905.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1087.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,905.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,905.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,905.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,905.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,760.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.49,1087.06,
ARROW RADIAL ARTERY CATH 20GX1 1/2,2103258,CDM,272,RC,,,outpatient,,,89.54,53.72,,67.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.35,80.59,
ARROW RADIAL ARTERY CATH KIT,2101291,CDM,272,RC,,,outpatient,,,124.57,74.74,,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,112.11,
ARROW ROTATOR DRIVE UNIT 03000R,2109488,CDM,272,RC,,,outpatient,,,281.98,169.19,,211.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,177.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,253.78,
ARROW TRAUMA KIT,2100136,CDM,272,RC,,,outpatient,,,241.04,144.62,,180.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.39,216.94,
ARROW TRAUMA SET,2103049,CDM,272,RC,,,outpatient,,,150.97,90.58,,113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.93,135.87,
ARROW TWIN CATH 16GX1 3/4,2102516,CDM,272,RC,,,outpatient,,,112.83,67.7,,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,101.55,
ARROW TWIN CATH 18GX 3/4,2101366,CDM,272,RC,,,outpatient,,,123.48,74.09,,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.3,111.13,
ARTHREX 3MM CANNULATED AC DRILL AR-2257D,2112244,CDM,272,RC,,,outpatient,,,732.66,439.6,,549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,586.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,659.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,461.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.12,659.39,
ARTHREX 4MM LONG CANN DRILL BIT AR-1204L,2112613,CDM,272,RC,,,outpatient,,,414.17,248.5,,310.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,310.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,310.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,260.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.86,372.75,
ARTHREX 9MM REAMER AR-1409,2111717,CDM,272,RC,,,outpatient,,,544.78,326.87,,408.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,408.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,408.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,343.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.63,490.3,
ARTHREX ACL TIGHTROPE DRILL PIN AR-1595T,2111899,CDM,272,RC,,,outpatient,,,343.95,206.37,,257.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,257.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,216.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.48,309.56,
ARTHREX ACL TIGHTROPE REPAIR KIT AR-2257,2112088,CDM,272,RC,,,outpatient,,,1343.64,806.18,,1007.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1074.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,286.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1007.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1209.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1007.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1007.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1007.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1007.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,846.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.31,1209.28,
ARTHREX BIO-TENODESIS KIT AR-1676DS,2112072,CDM,272,RC,C1713,HCPCS,outpatient,,,480.06,288.04,,360.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,360.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,432.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,360.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.36,432.05,
ARTHREX BONE MARROW BIOPSY KIT AR-1101DS,2112566,CDM,272,RC,,,outpatient,,,326.44,195.86,,244.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,244.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,293.8,
ARTHREX COOL CUT ASP 90 AR-9803A-90,2111704,CDM,272,RC,,,outpatient,,,342.03,205.22,,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,307.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,215.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.08,307.83,
ARTHREX DISP KIT MINI SUTURETAK AR-1322D,2111777,CDM,272,RC,,,outpatient,,,614.9,368.94,,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,553.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,387.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.99,553.41,
ARTHREX DISP KIT SHOULDER AR-1923-DS,2111711,CDM,272,RC,,,outpatient,,,509.23,305.54,,381.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,407.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,381.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,381.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,320.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.34,458.31,
ARTHREX DISSECTOR BLADE AR-8350DS,2111703,CDM,272,RC,,,outpatient,,,220.45,132.27,,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,198.41,
ARTHREX EXCALIBUR BLADE AR-8500EX,2111700,CDM,272,RC,,,outpatient,,,220.45,132.27,,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,198.41,
ARTHREX FIBERLOOP #2 AR-7234B,2112258,CDM,272,RC,,,outpatient,,,173.88,104.33,,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,156.49,
ARTHREX FLIP CUTTER REAMER AR-1204AF-85,2112248,CDM,272,RC,,,outpatient,,,867.18,520.31,,650.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,693.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,184.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,650.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,780.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,650.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,650.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,546.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.69,780.46,
ARTHREX J HOOK BOVIE AR-9801,2111979,CDM,272,RC,,,outpatient,,,274.67,164.8,,206,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,206,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,206,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,173.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.28,247.2,
ARTHREX KNOT PUSHER/SUTURE CUTT AR-4515,2111966,CDM,272,RC,,,outpatient,,,427.44,256.46,,320.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,320.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,320.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,269.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.58,384.7,
ARTHREX LASSO 406590W/4065W/406545L/45R,2111021,CDM,272,RC,,,outpatient,,,260.77,156.46,,195.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,195.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,164.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.43,234.69,
ARTHREX LASSO SHOULDER AR-4068-45R,2111710,CDM,272,RC,,,outpatient,,,407.92,244.75,,305.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,305.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,305.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,256.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.58,367.13,
ARTHREX LOW PROFILE REAM AR-1410LP,2112673,CDM,272,RC,,,outpatient,,,426.16,255.7,,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,268.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.32,383.54,
ARTHREX LOW PROFILE REAM AR-1411,2111683,CDM,272,RC,,,outpatient,,,572.57,343.54,,429.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,429.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,515.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,429.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,360.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.32,515.31,
ARTHREX MAIN PUMP TUBING AR-6410,2111705,CDM,272,RC,,,outpatient,,,241.14,144.68,,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.41,217.03,
ARTHREX MINI INSTRUMENT KIT AR-1322DSC,2113070,CDM,272,RC,,,outpatient,,,382.46,229.48,,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.37,344.21,
ARTHREX Nu 2 FIB LOOPNEED AR-7232-03,2112409,CDM,272,RC,,,outpatient,,,130.59,78.35,,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.76,117.53,
ARTHREX Nu 2 FIB LOOPNEED AR-7234,2111523,CDM,272,RC,,,outpatient,,,126.65,75.99,,94.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.95,113.99,
ARTHREX OVAL 8MM BLADE AR-8500OBE,2111701,CDM,272,RC,,,outpatient,,,220.45,132.27,,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,198.41,
ARTHREX ROUND BUR 8 FL BLADE AR-8500ORBE,2111702,CDM,272,RC,,,outpatient,,,220.45,132.27,,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,198.41,
ARTHREX TRANS ACL KIT AR-1897S,2111520,CDM,272,RC,,,outpatient,,,637.08,382.25,,477.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,477.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,573.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,477.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,401.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.54,573.37,
ARTHRO CARE ARTHROSCOPIC KIT 21-5430,2110665,CDM,272,RC,,,outpatient,,,297.9,178.74,,223.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,223.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.04,268.11,
ARTHRO CARE DRILL BIT,2110667,CDM,272,RC,,,outpatient,,,657.54,394.52,,493.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,493.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,591.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,493.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,414.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.73,591.79,
ARTHRO CARE GRAFT SCREW,2110666,CDM,272,RC,,,outpatient,,,220.67,132.4,,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,198.6,
ARTHRO CARE MULTI VAC WAND ASC4830-01,2109930,CDM,272,RC,,,outpatient,,,495.76,297.46,,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,312.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.58,446.18,
ARTHRO CARE PARAGON T2 WAND ASC5531-01,2109931,CDM,272,RC,,,outpatient,,,414.91,248.95,,311.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,311.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,311.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,261.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.02,373.42,
ARTHRO CARE SUPER TURBO WAND ASC4250-01,2109929,CDM,272,RC,,,outpatient,,,495.76,297.46,,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,312.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.58,446.18,
ARTHROSCOPY TUBING 87K 87100,2109743,CDM,272,RC,,,outpatient,,,104.71,62.83,,78.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.46,94.24,
ASH SPLIT CATH ASPC24,2109117,CDM,272,RC,,,outpatient,,,948.23,568.94,,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,853.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,597.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,853.41,
ASH SPLIT CATH ASPC28,2109086,CDM,272,RC,,,outpatient,,,948.23,568.94,,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,853.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,597.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,853.41,
ASH SPLIT CATH ASPC32,2109087,CDM,272,RC,,,outpatient,,,948.23,568.94,,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,853.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,597.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,853.41,
ASPIRATOR MECONIUM,2102006,CDM,272,RC,,,outpatient,,,54.1,32.46,,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,48.69,
B B NEEDLE STIMUPLEX 21X4*,2111046,CDM,272,RC,,,outpatient,,,16.48,9.89,,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,14.83,
B BRAUN 20G EPIDURAL CATH SET,2112876,CDM,272,RC,,,outpatient,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,43.52,
B BRAUN ADMINISTRATION SET 352239,2112746,CDM,272,RC,,,outpatient,,,7.65,4.59,,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,6.89,
B BRAUN DOCK STA ESP COMBINED 333174,2111799,CDM,272,RC,,,outpatient,,,80.59,48.35,,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,72.53,
B BRAUN FILTER NEEDLE 19GX1 1/2 415030,2111919,CDM,272,RC,,,outpatient,,,1.37,0.82,,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,1.23,
B BRAUN I V CATH 14G X 1 1/4,2112736,CDM,272,RC,,,outpatient,,,7.65,4.59,,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,6.89,
B BRAUN I V CATH 16G X 1 1/4,2112737,CDM,272,RC,,,outpatient,,,7.65,4.59,,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,6.89,
B BRAUN I V CATH 18G X 1 1/4,2112360,CDM,272,RC,,,outpatient,,,65.92,39.55,,49.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.51,59.33,
B BRAUN I V CATH 18G X 1.75,2113152,CDM,272,RC,,,outpatient,,,9.73,5.84,,7.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.99,8.76,
B BRAUN I V CATH 18Gx2.5 25256102,2112440,CDM,272,RC,,,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.77,25.33,
B BRAUN I V CATH 20G x 1.76,2113151,CDM,272,RC,,,outpatient,,,8.84,5.3,,6.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,7.96,
B BRAUN I V CATH 20G*,2112359,CDM,272,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
B BRAUN I V CATH 22G*,2112358,CDM,272,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
B BRAUN I V CATH 24G,2112423,CDM,272,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
B BRAUN NEEDLE 22 3 1/8 30 DEGREE 333684,2110839,CDM,272,RC,,,outpatient,,,89.06,53.44,,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.25,80.15,
B BRAUN NEEDLE 22X2*,2109757,CDM,272,RC,,,outpatient,,,80.32,48.19,,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,72.29,
B BRAUN NEEDLE 25X5 333875,2110967,CDM,272,RC,,,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,57.78,
B BRAUN NEEDLE 26X3.5 333300,2111048,CDM,272,RC,,,outpatient,,,11.47,6.88,,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,10.32,
B BRAUN NEEDLE STIMUPLEX 20X6 4894278,2111047,CDM,272,RC,,,outpatient,,,87.69,52.61,,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.97,78.92,
B BRAUN NEEDLE STIMUPLEX 22X1 333691,2109759,CDM,272,RC,,,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,57.78,
B BRAUN NEEDLE STIMUPLEX 22X2 4894502,2111782,CDM,272,RC,,,outpatient,,,37.71,22.63,,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,33.94,
B BRAUN NEEDLE STIMUPLEX 25X31/2 333853,2110968,CDM,272,RC,,,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,57.78,
B BRUAN NEEDLE 22X3 1/8 333674,2109758,CDM,272,RC,,,outpatient,,,80.32,48.19,,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,72.29,
BAG DECANTER 10-102,2109577,CDM,272,RC,,,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,6.49,
BAIR HUGGER UPPER BLANKET*,2103031,CDM,272,RC,,,outpatient,,,61.8,37.08,,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,55.62,
BALLOON DILATOR CATH 24F 8MM,2103222,CDM,272,RC,,,outpatient,,,394.97,236.98,,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,248.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,355.47,
BALLOON DILATOR CATH 30F,2108439,CDM,272,RC,,,outpatient,,,1080.42,648.25,,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,972.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,680.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.38,972.38,
BALLOON DILATOR CATH 36F 12MM,2103221,CDM,272,RC,,,outpatient,,,394.97,236.98,,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,248.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,355.47,
BALLOON DILATOR CATH 42F,2108440,CDM,272,RC,,,outpatient,,,1080.42,648.25,,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,972.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,810.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,680.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.38,972.38,
BALLOON DILATOR CATH 48F/14MM 16X8,2108359,CDM,272,RC,,,outpatient,,,460.65,276.39,,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,290.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.39,414.59,
BALLOON DILATOR CATH 48MM 16MM,2103220,CDM,272,RC,,,outpatient,,,394.97,236.98,,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,248.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.93,355.47,
BALLOON DILATOR CATH 54F/18MM/18X8,2108358,CDM,272,RC,,,outpatient,,,460.65,276.39,,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,290.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.39,414.59,
BANDAGE COMPRESSION 3,2102960,CDM,272,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
BARD ATLAS BALLOON AT-75124,2109404,CDM,272,RC,C1725,HCPCS,outpatient,,,805.44,483.26,,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,644.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,507.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.03,724.9,
BARD CONQUEST BALLOON CQ-5052,2109411,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD CONQUEST BALLOON CQ-5054,2109412,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD CONQUEST BALLOON CQ-5062,2109413,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD CONQUEST BALLOON CQ-5064,2109414,CDM,272,RC,C1725,HCPCS,outpatient,,,573.96,344.38,,430.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,430.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,516.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,430.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,361.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.6,516.56,
BARD CONQUEST BALLOON CQ-5074,2109416,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD CONQUEST BALLOON CQ-5082,2109417,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD CONQUEST BALLOON CQ-5084,2109418,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD CONQUEST BALLOON CQ-5092,2109419,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD CONQUEST BALLOON CQ-5094,2109420,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD CONQUEST BALLOON CQ-75104,2109421,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD DORADO 6X4 DR-4064,2110920,CDM,272,RC,C1725,HCPCS,outpatient,,,419.27,251.56,,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,264.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,377.34,
BARD DORADO 7X4 DR-4074,2110921,CDM,272,RC,C1725,HCPCS,outpatient,,,419.27,251.56,,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,264.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,377.34,
BARD DORADO 8X4 DR-4084,2110922,CDM,272,RC,C1725,HCPCS,outpatient,,,419.27,251.56,,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,264.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,377.34,
BARD DORADO 9X4 DR-4094,2110923,CDM,272,RC,C1725,HCPCS,outpatient,,,441.33,264.8,,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,397.2,
BARD DORADO CATH 5X10 DR-80510,2110963,CDM,272,RC,C1725,HCPCS,outpatient,,,441.33,264.8,,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,397.2,
BARD GROSHONG CATH 4 FR 7717412,2111339,CDM,272,RC,,,outpatient,,,123.28,73.97,,92.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.26,110.95,
BARD INFLATION DEVICE MX-30,2109406,CDM,272,RC,,,outpatient,,,323.68,194.21,,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,203.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.32,291.31,
BARD MICROPUNCTURE KIT 5F,2109391,CDM,272,RC,,,outpatient,,,431.79,259.07,,323.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,323.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,323.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,272.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.47,388.61,
BARD NIAGARA SLIM CATH KI 12-15CM5553150,2111706,CDM,272,RC,,,outpatient,,,493.64,296.18,,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,444.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,310.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,444.28,
BARD NIAGARA SLIM CATH KI 12-20CM5553200,2111445,CDM,272,RC,,,outpatient,,,493.64,296.18,,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,444.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,310.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,444.28,
BARD OPTI PLAST BALLOON XT-75410,2110797,CDM,272,RC,,,outpatient,,,507.53,304.52,,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,319.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.99,456.78,
BARD OPTI PLAST PTA CATH XT-100102,2109615,CDM,272,RC,C1725,HCPCS,outpatient,,,492.79,295.67,,369.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,369.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,369.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,310.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.97,443.51,
BARD OPTI PLAST PTA CATH XT-100104,2109616,CDM,272,RC,C1725,HCPCS,outpatient,,,507.53,304.52,,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,319.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.99,456.78,
BARD PCI INPUT PS 5F 050011,2109500,CDM,272,RC,C1894,HCPCS,outpatient,,,152.67,91.6,,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,137.4,
BARD PCI INPUT PS 6R 060011,2109501,CDM,272,RC,C1894,HCPCS,outpatient,,,152.67,91.6,,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,137.4,
BARD PCI INPUT PS 7F 070011,2109502,CDM,272,RC,,,outpatient,,,152.67,91.6,,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,137.4,
BARD PERMAFIX FIXATION SYSTEM,2111749,CDM,272,RC,,,outpatient,,,5391.49,3234.89,,4043.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4313.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1148.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1148.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1159.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4852.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4043.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4043.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4043.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4043.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3396.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.72,4852.34,
BARD PTA BALLOON CATH CQ-7584,2109607,CDM,272,RC,C1725,HCPCS,outpatient,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,472.73,
BARD PTA BALLOON CATH RV-8032,2109586,CDM,272,RC,C1725,HCPCS,outpatient,,,474.44,284.66,,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,298.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,427,
BARD PTA BALLOON CATH RV-8042,2109587,CDM,272,RC,C1725,HCPCS,outpatient,,,474.44,284.66,,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,298.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,427,
BARD PTA BALLOON CATH XT-5052,2109588,CDM,272,RC,C1725,HCPCS,outpatient,,,474.44,284.66,,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,298.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,427,
BARD SITE RITE 18G GUIDE KIT 9001C0212,2109351,CDM,272,RC,,,outpatient,,,120.48,72.29,,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,108.43,
BARD SITE RITE NEEDLE 18G ONLY,2109374,CDM,272,RC,,,outpatient,,,45.07,27.04,,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,40.56,
BARD SITE RITE NEEDLE 21G ONLY,2109375,CDM,272,RC,,,outpatient,,,120.48,72.29,,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,108.43,
BILE BAG,2100103,CDM,272,RC,,,outpatient,,,45.9,27.54,,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,41.31,
BIOMET 1/4 TUBULAR PLATE 8240-60-007,2110588,CDM,272,RC,,,outpatient,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,173.58,
BIOMET 4.0 SOLID DRILL BIT T SMALL FRAG,2109856,CDM,272,RC,,,outpatient,,,226.74,136.04,,170.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,170.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.46,204.07,
BIOMET CANCELLOUS CHIPS 4-10MM 08A024,2112330,CDM,272,RC,,,outpatient,,,487.08,292.25,,365.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,389.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,365.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,365.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,306.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.8,438.37,
BIOMET CANN DRILL BIT S COU 8290-30-070,2110275,CDM,272,RC,,,outpatient,,,521.51,312.91,,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,469.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.86,469.36,
BIOMET DRILL BIT,2112256,CDM,272,RC,,,outpatient,,,268.53,161.12,,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.02,241.68,
BIOMET DRILL BIT,2112257,CDM,272,RC,,,outpatient,,,246.95,148.17,,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,222.26,
BIOMET DRILL BIT MINI FRAG,2109771,CDM,272,RC,,,outpatient,,,377.8,226.68,,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,238.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.41,340.02,
BIOMET DRILL BIT T SMALL FRAG,2109854,CDM,272,RC,,,outpatient,,,268.27,160.96,,201.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.97,241.44,
BIOMET DRILL CANN T SMALL FRAG,2111596,CDM,272,RC,,,outpatient,,,600.18,360.11,,450.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,450.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,450.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,378.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.98,540.16,
BIOMET DRILL GUIDE,2112288,CDM,272,RC,,,outpatient,,,535.16,321.1,,401.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,401.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,481.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,401.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,337.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.65,481.64,
BIOMET DRILL TWIST,2112781,CDM,272,RC,C1713,HCPCS,outpatient,,,221.54,132.92,,166.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.39,199.39,
BIOMET SHOU DRILL BIT 405883,2111909,CDM,272,RC,,,outpatient,,,463.59,278.15,,347.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,347.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,347.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.99,417.23,
BIOMET SOLID DRILL BIT,2111996,CDM,272,RC,C1713,HCPCS,outpatient,,,254.33,152.6,,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,160.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.11,228.9,
BIOMET SOLID S DRILL BIT 8290-32-070,2112057,CDM,272,RC,,,outpatient,,,268.53,161.12,,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.02,241.68,
BIOMET SOLID S DRILL BIT T SMALL FRAG,2109852,CDM,272,RC,,,outpatient,,,276.74,166.04,,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,174.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.7,249.07,
BIOPATCH GUARDIVA FP-23-AD008,2112263,CDM,272,RC,,,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,6.49,
BIOPSY CLAMP MUSCLE,2103138,CDM,272,RC,,,outpatient,,,195.88,117.53,,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,123.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.14,176.29,
BIOPSY INST MC1416,2109645,CDM,272,RC,,,outpatient,,,329.47,197.68,,247.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,247.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,247.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,207.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.51,296.52,
BIOPSY INST MC1820,2111891,CDM,272,RC,,,outpatient,,,127.31,76.39,,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,114.58,
BIOPSY PUNCH 2MM 95391111,2112523,CDM,272,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
BIOPSY PUNCH 3MM,2108948,CDM,272,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
BIOPSY PUNCH 4MM 6422DP0400,2108949,CDM,272,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
BIOPSY PUNCH 5MM BP50,2109119,CDM,272,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
BIOPSY PUNCH 6MM BP60,2109120,CDM,272,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
BITE BLOCKS MAJ-1632,2111090,CDM,272,RC,,,outpatient,,,22.66,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,20.39,
BLADE BEAVER 376700,2109348,CDM,272,RC,,,outpatient,,,89.65,53.79,,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.37,80.69,
BLADE BEAVER 6700,2109349,CDM,272,RC,,,outpatient,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,11.55,
BLADE BEAVER MINI BEAVER6600,2113031,CDM,272,RC,,,outpatient,,,91.52,54.91,,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,82.37,
BLADE BEAVER MINI BEAVER6900,2112439,CDM,272,RC,,,outpatient,,,44.53,26.72,,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.12,40.08,
BLADE LARYN SIZE 3 DISP,2109231,CDM,272,RC,,,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
BLADE SHIELD DEVON,2103254,CDM,272,RC,,,outpatient,,,7.53,4.52,,5.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,6.78,
BONE MARROW TRAY,2100268,CDM,272,RC,,,outpatient,,,38.61,23.17,,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,34.75,
BONE WIRE,2100408,CDM,272,RC,,,outpatient,,,56.01,33.61,,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,50.41,
BOS SC AMPLATZ SUPER STIFF 46-523,2109461,CDM,272,RC,C1769,HCPCS,outpatient,,,230.22,138.13,,172.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,172.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,145.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.17,207.2,
BOS SC ARTERIAL ENTRY NEEDLE 44-169,2109460,CDM,272,RC,,,outpatient,,,27.9,16.74,,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,25.11,
BOS SC BALLOON DILATOR M00558480,2111410,CDM,272,RC,,,outpatient,,,676.4,405.84,,507.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,507.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,608.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,507.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,426.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.59,608.76,
BOS SC BALLOON DILATOR M00558500,2111411,CDM,272,RC,,,outpatient,,,420.76,252.46,,315.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,315.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,315.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.21,378.68,
BOS SC ESOPHAGEAL DILATOR M00558490,2113071,CDM,272,RC,,,outpatient,,,663.18,397.91,,497.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,497.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,596.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,497.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,497.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,497.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,497.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,417.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.89,596.86,
BOS SC FLOW SWITCH 44-201,2109458,CDM,272,RC,,,outpatient,,,38.24,22.94,,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.84,34.42,
BOS SC GLIDEWIRE 46-155,2109478,CDM,272,RC,C1769,HCPCS,outpatient,,,279.55,167.73,,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,251.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,176.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.28,251.6,
BOS SC GUIDEWIRE 46-154,2109666,CDM,272,RC,C1769,HCPCS,outpatient,,,419.27,251.56,,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,264.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,377.34,
BOS SC PEG KIT PULL 20F M00568201,2112505,CDM,272,RC,,,outpatient,,,230.57,138.34,,172.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,172.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,145.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.24,207.51,
BOS SC PUSH G TUBE 20F M00568211,2112269,CDM,272,RC,,,outpatient,,,211.02,126.61,,158.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,158.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,158.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,132.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.24,189.92,
BOS SC RAD ANGLED GLIDEWIRE 46-305B,2109462,CDM,272,RC,C1769,HCPCS,outpatient,,,466.32,279.79,,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.55,419.69,
BOS SC STD PULL PEG KIT 24 FR M00568241,2111378,CDM,272,RC,,,outpatient,,,534.62,320.77,,400.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,400.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,481.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,400.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,336.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.54,481.16,
BOS SC SYRINGE M00550601,2111407,CDM,272,RC,,,outpatient,,,263.9,158.34,,197.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,197.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.07,237.51,
BSD BAG*,2100162,CDM,272,RC,,,outpatient,,,42.34,25.4,,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,38.11,
BUSSE 10MM CURVED CURETTE,2109294,CDM,272,RC,,,outpatient,,,20.76,12.46,,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,18.68,
BUSSE 7MM CURVED CURETTE,2108983,CDM,272,RC,,,outpatient,,,20.76,12.46,,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,18.68,
BUSSE 7MM UTERINE CURETTE,2108566,CDM,272,RC,,,outpatient,,,18.58,11.15,,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.81,16.72,
BUSSE 8MM STRAIGHT UTERINE,2103300,CDM,272,RC,,,outpatient,,,21.31,12.79,,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,19.18,
BUSSE 9MM CURVED CURETTE,2108984,CDM,272,RC,,,outpatient,,,22.95,13.77,,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.66,
BUTTERFLY 21G,2100150,CDM,272,RC,,,outpatient,,,11.57,6.94,,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,10.41,
BUTTERFLY 23G,2100365,CDM,272,RC,,,outpatient,,,11.57,6.94,,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,10.41,
BUTTERFLY 25G,2100146,CDM,272,RC,,,outpatient,,,9.45,5.67,,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,8.51,
C ARM DRAPE GE OEC/STERIGEAR 10109,2109909,CDM,272,RC,,,outpatient,,,110.64,66.38,,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.67,99.58,
C ARM FLOUOSCAN 10131,2109739,CDM,272,RC,,,outpatient,,,78.4,47.04,,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.06,70.56,
C ARM FOOTSWITCH COVER E9100AD,2111806,CDM,272,RC,,,outpatient,,,6.18,3.71,,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,5.56,
C-ARM COVER 36X28 10247 STERI GEAR,2102411,CDM,272,RC,,,outpatient,,,12.36,7.42,,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,11.12,
CABOT Y CONNECTOR TUBING,2102410,CDM,272,RC,,,outpatient,,,282.84,169.7,,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,178.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,254.56,
CALGON HYDRASORB 3 1/2 X3 1/8,2102864,CDM,272,RC,,,outpatient,,,21.58,12.95,,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,19.42,
CALGON HYDRASORB 4X4*,2100007,CDM,272,RC,,,outpatient,,,9.27,5.56,,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,8.34,
CALGON HYDRASORB 4X8*,2102865,CDM,272,RC,,,outpatient,,,10.3,6.18,,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,9.27,
CALGON KALOSTAT 10X20,2102860,CDM,272,RC,,,outpatient,,,178.39,107.03,,133.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,112.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.55,160.55,
CALGON KALOSTAT 2MG,2102739,CDM,272,RC,,,outpatient,,,66.38,39.83,,49.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.6,59.74,
CALGON KALOSTAT 2X2,2102738,CDM,272,RC,,,outpatient,,,22.4,13.44,,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.16,
CALGON KALOSTAT 3X4 3/4 7.5X12,2102861,CDM,272,RC,,,outpatient,,,79.23,47.54,,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,71.31,
CAMERA SLEEVE 5 inch X 96 inch,2102456,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
CANNULA END TIDAL 77-4706F-25,2109142,CDM,272,RC,,,outpatient,,,29.39,17.63,,22.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.02,26.45,
CARDIOVASCULAR INSTR,2100383,CDM,272,RC,,,outpatient,,,11.77,7.06,,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,10.59,
CARE V MUELLE A213 REPO SCISOR 89-5103,2112242,CDM,272,RC,,,outpatient,,,151.41,90.85,,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.02,136.27,
CAREFUSION ACHIEVE NEEDLE BIOPSY NEEDLE,2112530,CDM,272,RC,,,outpatient,,,126.75,76.05,,95.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.97,114.08,
CARPAL TUNNER RELEASE SYSTEM 81010-1,2109761,CDM,272,RC,,,outpatient,,,397.84,238.7,,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,358.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,250.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.52,358.06,
CAST PADDING STERILE 3 inch 070723626530,2109912,CDM,272,RC,,,outpatient,,,14.53,8.72,,10.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.98,13.08,
CAST PADDING STERILE 4 inch,2109913,CDM,272,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
CAST PADDING STERILE 6 inch 070723626560,2109914,CDM,272,RC,,,outpatient,,,21.31,12.79,,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,19.18,
CATH ANGLE DRAIN 4 WING 26FR,2101627,CDM,272,RC,,,outpatient,,,260.06,156.04,,195.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,195.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.29,234.05,
CATH CONDUM LG,2109079,CDM,272,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
CATH COUDE 12FR*,2112508,CDM,272,RC,,,outpatient,,,104.91,62.95,,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.5,94.42,
CATH COUDE 16F URETHERAL,2108335,CDM,272,RC,C1758,HCPCS,outpatient,,,55.19,33.11,,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.31,49.67,
CATH COUDE 16F W/BALLOON,2109035,CDM,272,RC,,,outpatient,,,140.14,84.08,,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,126.13,
CATH COUDE 18F W/BALLOON,2109036,CDM,272,RC,,,outpatient,,,140.14,84.08,,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,126.13,
CATH COUDE 5CC W/BALLOON,2109034,CDM,272,RC,,,outpatient,,,140.14,84.08,,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.71,126.13,
CATH EMBOLECTOMY 3 FR,2100462,CDM,272,RC,C1757,HCPCS,outpatient,,,227.77,136.66,,170.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,170.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.67,204.99,
CATH EMBOLECTOMY 4FR,2101621,CDM,272,RC,C1757,HCPCS,outpatient,,,402.12,241.27,,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,253.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.39,361.91,
CATH EMBOLECTOMY 5FR,2101622,CDM,272,RC,C1757,HCPCS,outpatient,,,402.12,241.27,,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,253.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.39,361.91,
CATH EMBOLECTOMY 6FR,2101623,CDM,272,RC,C1757,HCPCS,outpatient,,,446.93,268.16,,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,281.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.58,402.24,
CATH EMBOLECTOMY 7FR,2101624,CDM,272,RC,C1757,HCPCS,outpatient,,,446.93,268.16,,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,281.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.58,402.24,
CATH FOGARTY BILIARY BALLOON 5FR,2109335,CDM,272,RC,C1757,HCPCS,outpatient,,,441.33,264.8,,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,397.2,
CATH FORGARTY ARTERIAL EMBOLECTOMY 4 FR,2112820,CDM,272,RC,C1757,HCPCS,outpatient,,,152.99,91.79,,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,137.69,
CATH MUSHROOM 10FR,2100454,CDM,272,RC,,,outpatient,,,88.05,52.83,,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.04,79.25,
CATH MUSHROOM 12FR,2101606,CDM,272,RC,,,outpatient,,,161.79,97.07,,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,145.61,
CATH MUSHROOM 16FR,2101608,CDM,272,RC,,,outpatient,,,132.93,79.76,,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.24,119.64,
CATH MUSHROOM 18FR,2101609,CDM,272,RC,,,outpatient,,,147.68,88.61,,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,132.91,
CATH MUSHROOM 20FR,2101610,CDM,272,RC,,,outpatient,,,136.96,82.18,,102.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.06,123.26,
CATH MUSHROOM 22FR,2101611,CDM,272,RC,,,outpatient,,,146.3,87.78,,109.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.98,131.67,
CATH MUSHROOM 24FR,2101748,CDM,272,RC,,,outpatient,,,125.72,75.43,,94.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.76,113.15,
CATH MUSHROOM 26FR,2101612,CDM,272,RC,,,outpatient,,,147.68,88.61,,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,132.91,
CATH MUSHROOM 28FR,2101613,CDM,272,RC,,,outpatient,,,147.68,88.61,,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,132.91,
CATH MUSHROOM 30FR,2101614,CDM,272,RC,,,outpatient,,,147.68,88.61,,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,132.91,
CATH MUSHROOM 32FR,2101615,CDM,272,RC,,,outpatient,,,147.68,88.61,,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,132.91,
CATH MUSHROOM 34FR,2101963,CDM,272,RC,,,outpatient,,,133.67,80.2,,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.39,120.3,
CATH MUSHROOM 36FR,2102040,CDM,272,RC,,,outpatient,,,170.06,102.04,,127.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,107.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.85,153.05,
CATH MUSHROOM 38FR,2101616,CDM,272,RC,,,outpatient,,,132.93,79.76,,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.24,119.64,
CATH MUSHROOM 40FR,2101617,CDM,272,RC,,,outpatient,,,147.68,88.61,,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.26,132.91,
CATH OLIVE 3FR,2101419,CDM,272,RC,,,outpatient,,,574.5,344.7,,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,517.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,361.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,517.05,
CATH OLIVE 4FR,2101418,CDM,272,RC,,,outpatient,,,574.5,344.7,,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,517.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,361.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,517.05,
CATH OLIVE 5FR,2101417,CDM,272,RC,,,outpatient,,,517.13,310.28,,387.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,387.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,387.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,325.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.96,465.42,
CATH OLIVE 6FR,2101416,CDM,272,RC,,,outpatient,,,574.5,344.7,,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,517.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,361.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,517.05,
CATH OLIVE TIP WOVEN 4FR,2101619,CDM,272,RC,,,outpatient,,,625.93,375.56,,469.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,469.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,469.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,394.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.25,563.34,
CATH PEZZER 26FR,2102055,CDM,272,RC,,,outpatient,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,124.42,
CATH PEZZER 28FR,2102053,CDM,272,RC,,,outpatient,,,78.14,46.88,,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,70.33,
CATH PEZZER 30FR,2102042,CDM,272,RC,,,outpatient,,,138.56,83.14,,103.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.39,124.7,
CATH PEZZER 34FR,2102043,CDM,272,RC,,,outpatient,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,124.42,
CATH PEZZER 36FR,2102044,CDM,272,RC,,,outpatient,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,124.42,
CATH PEZZER 38FR,2102045,CDM,272,RC,,,outpatient,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,124.42,
CATH PEZZER 40FR,2102052,CDM,272,RC,,,outpatient,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,124.42,
CATH PEZZER 45FR,2102056,CDM,272,RC,,,outpatient,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,124.42,
CATH PHILLIPS 10FR,2108365,CDM,272,RC,,,outpatient,,,727.21,436.33,,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,458.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.01,654.49,
CATH PHILLIPS 12FR,2101778,CDM,272,RC,,,outpatient,,,707.82,424.69,,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,637.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,445.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,637.04,
CATH PHILLIPS 14FR,2101774,CDM,272,RC,,,outpatient,,,707.82,424.69,,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,637.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,445.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,637.04,
CATH PHILLIPS 16FR,2101775,CDM,272,RC,,,outpatient,,,637.06,382.24,,477.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,509.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,477.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,573.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,477.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,401.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.53,573.35,
CATH PHILLIPS 18FR,2102834,CDM,272,RC,,,outpatient,,,864.53,518.72,,648.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,184.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,648.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,778.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,648.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,544.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.14,778.08,
CATH PHILLIPS 20FR,2101628,CDM,272,RC,,,outpatient,,,707.82,424.69,,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,637.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,445.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,637.04,
CATH PHILLIPS 22FR,2102835,CDM,272,RC,,,outpatient,,,944.66,566.8,,708.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,708.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,850.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,708.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,595.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.56,850.19,
CATH PHILLIPS 24FR,2108364,CDM,272,RC,,,outpatient,,,727.21,436.33,,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,458.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.01,654.49,
CATH PHILLIPS 8FR,2101777,CDM,272,RC,,,outpatient,,,707.82,424.69,,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,637.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,530.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,445.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.03,637.04,
CATH ROBINSON 10FR,2100039,CDM,272,RC,,,outpatient,,,33.88,20.33,,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,30.49,
CATH ROBINSON 12FR,2100040,CDM,272,RC,,,outpatient,,,22.95,13.77,,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.66,
CATH ROBINSON 14FR,2100043,CDM,272,RC,,,outpatient,,,45.9,27.54,,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,41.31,
CATH ROBINSON 16F STERILE DYND13516,2100037,CDM,272,RC,,,outpatient,,,36.34,21.8,,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,32.71,
CATH ROBINSON 18F,2100038,CDM,272,RC,,,outpatient,,,11.99,7.19,,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,10.79,
CATH ROBINSON 18F,2102912,CDM,272,RC,,,outpatient,,,10.65,6.39,,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,9.59,
CATH ROBINSON 20F,2100042,CDM,272,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
CATH ROBINSON 22F,2102757,CDM,272,RC,,,outpatient,,,19.39,11.63,,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,17.45,
CATH ROBINSON 8FR,2100041,CDM,272,RC,,,outpatient,,,19.39,11.63,,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.97,17.45,
CATH SECURE,2101157,CDM,272,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
CATH TAUT CHOLONGIOGRAM 20018-M56,2108786,CDM,272,RC,,,outpatient,,,232.12,139.27,,174.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,146.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.56,208.91,
CATH TAUT INTRODUCER PI-93,2108788,CDM,272,RC,,,outpatient,,,178.55,107.13,,133.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,112.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.58,160.7,
CATH THORACIC STRAIGHT 12F,2103060,CDM,272,RC,,,outpatient,,,88.24,52.94,,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,79.42,
CATH THORACIC STRAIGHT 16F,2103061,CDM,272,RC,,,outpatient,,,88.24,52.94,,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,79.42,
CATH THORACIC STRAIGHT 20F,2103062,CDM,272,RC,,,outpatient,,,88.24,52.94,,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,79.42,
CATH THORACIC STRAIGHT 24F,2103063,CDM,272,RC,,,outpatient,,,88.24,52.94,,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,79.42,
CATH THORACIC STRAIGHT 28F,2102984,CDM,272,RC,,,outpatient,,,91.25,54.75,,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.7,82.13,
CATH THORACIC STRAIGHT 32F,2102441,CDM,272,RC,,,outpatient,,,91.52,54.91,,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,82.37,
CATH THORACIC STRAIGHT 36F,2102440,CDM,272,RC,,,outpatient,,,91.52,54.91,,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,82.37,
CATH THORACIC STRAIGHT 40F,2102442,CDM,272,RC,,,outpatient,,,91.52,54.91,,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.75,82.37,
CATH URETHRAL CONE TIP 10F,2102650,CDM,272,RC,C1758,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,120.23,
CATH WHISTLE,2108367,CDM,272,RC,,,outpatient,,,630.5,378.3,,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,397.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,567.45,
CATH WHISTLE TIP 3F,2108366,CDM,272,RC,,,outpatient,,,630.5,378.3,,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,397.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,567.45,
CATH WHISTLE TIP 5F,2108368,CDM,272,RC,,,outpatient,,,630.5,378.3,,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,397.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,567.45,
CATH WHISTLE TIP 6F,2108369,CDM,272,RC,,,outpatient,,,630.5,378.3,,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,397.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.19,567.45,
CATHETER CHOLANGIOGRAPHY 19G CC019,2109198,CDM,272,RC,,,outpatient,,,233.03,139.82,,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,146.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,209.73,
CATHETER SELF FEMALE 14 FR 430614,2111921,CDM,272,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
CAUTERY SURGICAL HI TEMP,2102947,CDM,272,RC,,,outpatient,,,67.37,40.42,,50.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.8,60.63,
CELL PROCESSING FILTER,2109956,CDM,272,RC,,,outpatient,,,66.2,39.72,,49.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.56,59.58,
CELL PROCESSING KIT,2109954,CDM,272,RC,,,outpatient,,,662,397.2,,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,417.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,595.8,
CELL PROCESSING SUCTION KIT,2109955,CDM,272,RC,,,outpatient,,,98.56,59.14,,73.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.19,88.7,
CHOLANGIOCATH 19GX30,2102320,CDM,272,RC,,,outpatient,,,58.73,35.24,,44.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.03,52.86,
CHOLANGIOGRAM CATH OPERATIVE 20018-M55,2111344,CDM,272,RC,,,outpatient,,,207.9,124.74,,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,130.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.6,187.11,
CIRCON HELICAL STONE BASKET,2108345,CDM,272,RC,,,outpatient,,,358.26,214.96,,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,225.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.41,322.43,
CIRCUMCISION SUPPLIES,2100324,CDM,272,RC,,,outpatient,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.28,260.37,
CIVCO ENDOCAVITY NEEDLE GUIDE 613245,2111895,CDM,272,RC,,,outpatient,,,74.86,44.92,,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.34,67.37,
CIVCO US PROBE COVERS 610-001,2110778,CDM,272,RC,,,outpatient,,,47.8,28.68,,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,43.02,
CO SET,2102342,CDM,272,RC,,,outpatient,,,342.35,205.41,,256.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,256.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,215.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.15,308.12,
COBAN 4 inch STERILE*,2109865,CDM,272,RC,,,outpatient,,,46.35,27.81,,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,41.72,
COBAN 6 inch STERILE*,2109866,CDM,272,RC,,,outpatient,,,9.27,5.56,,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,8.34,
COBAN BANDAGE 1IN,2103128,CDM,272,RC,,,outpatient,,,6.9,4.14,,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.41,6.21,
COBAN BANDAGE 1IN,2112201,CDM,272,RC,,,outpatient,,,2.46,1.48,,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.5,2.21,
COBAN BANDAGE 2IN*,2100623,CDM,272,RC,,,outpatient,,,6.18,3.71,,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,5.56,
COMBINED SPINAL NEEDLE 18G W/DOC 333174,2112177,CDM,272,RC,,,outpatient,,,75.95,45.57,,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.56,68.36,
COMBITUBE ENDO TRACH KIT,2109549,CDM,272,RC,,,outpatient,,,353.06,211.84,,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,222.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,317.75,
CONFORMING BANDAGE Number 4 GR0404-1,2109456,CDM,272,RC,A6446,HCPCS,outpatient,,,82.43,49.46,,61.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.89,74.19,
CONMED 4.2 STER ULTRACUT SHAVR C9405A,2109884,CDM,272,RC,,,outpatient,,,138.45,83.07,,103.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.37,124.61,
CONMED ACL KIT 8800,2110953,CDM,272,RC,,,outpatient,,,401.24,240.74,,300.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,300.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,300.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,252.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.21,361.12,
CONMED ARTHROSCOPY INFLOW OUTFLOW,2109832,CDM,272,RC,,,outpatient,,,264.8,158.88,,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,238.32,
CONMED BLADE CRESENTIC MICRO 5023-171,2112146,CDM,272,RC,,,outpatient,,,182.76,109.66,,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,115.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,164.48,
CONMED BLADE ELECTRODE,2108444,CDM,272,RC,,,outpatient,,,43.82,26.29,,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,39.44,
CONMED BLADE LG BONE 5071-531,2110708,CDM,272,RC,,,outpatient,,,313.34,188,,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,197.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,282.01,
CONMED BLADE SAG COARSE 5023-133,2110705,CDM,272,RC,,,outpatient,,,67.68,40.61,,50.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.87,60.91,
CONMED BLADE SAG FINE 5023-,2110709,CDM,272,RC,,,outpatient,,,286.87,172.12,,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,180.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.78,258.18,
CONMED BLADE SAG FINE 5023-118,2110580,CDM,272,RC,,,outpatient,,,182.76,109.66,,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,115.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,164.48,
CONMED BLADE SAG FINE 5023-143,2111655,CDM,272,RC,,,outpatient,,,182.76,109.66,,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,115.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,164.48,
CONMED GATOR CUTTER 4.2 9263A,2109900,CDM,272,RC,,,outpatient,,,78.83,47.3,,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,70.95,
CONMED GATOR MENISUS CUTTER C9264,2109886,CDM,272,RC,,,outpatient,,,78.83,47.3,,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.15,70.95,
CONMED LINV ACL DISP KIT 8800,2110581,CDM,272,RC,,,outpatient,,,282.42,169.45,,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,177.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.87,254.18,
CONMED LINV BUR 5091-228,2110407,CDM,272,RC,,,outpatient,,,104.36,62.62,,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,93.92,
CONMED LINV BUR 5091-236,2108551,CDM,272,RC,,,outpatient,,,158.5,95.1,,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,99.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.48,142.65,
CONMED LINV BUR 5091-264,2110406,CDM,272,RC,,,outpatient,,,220.67,132.4,,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,198.6,
CONMED LINV DRILL BIT 8595,2110723,CDM,272,RC,,,outpatient,,,386.17,231.7,,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,243.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,347.55,
CONMED LINV SCREW C8700,2110579,CDM,272,RC,,,outpatient,,,192.02,115.21,,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.34,172.82,
CONMED LINV SCREW C8710,2110724,CDM,272,RC,,,outpatient,,,192.02,115.21,,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.34,172.82,
CONMED MULTIFUNCTION SYS 60-6010-003,2102898,CDM,272,RC,,,outpatient,,,451.94,271.16,,338.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,338.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,338.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,284.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.6,406.75,
CONMED OSC BLADE 5071-123,2110461,CDM,272,RC,,,outpatient,,,313.34,188,,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,197.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.2,282.01,
CONMED OSC BLADE 5071-180,2110706,CDM,272,RC,,,outpatient,,,176.53,105.92,,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,111.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.17,158.88,
CONMED OSC BLADE 5071-181,2110707,CDM,272,RC,,,outpatient,,,176.53,105.92,,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,111.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.17,158.88,
CONMED PUDDLEVAC SUCTION 9321,2109883,CDM,272,RC,,,outpatient,,,120.48,72.29,,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,108.43,
CONMED SCREW C8031/C8034/C8035/C037,2110954,CDM,272,RC,,,outpatient,,,200.61,120.37,,150.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.1,180.55,
CONMED SHAVER HEAD OVAL BUR H9102,2109765,CDM,272,RC,,,outpatient,,,270.11,162.07,,202.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,170.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.35,243.1,
CONMED SPATULA 60-5274-032,2102899,CDM,272,RC,,,outpatient,,,776.12,465.67,,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,488.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.03,698.51,
CONMED SPHER BURR 3.5 H9110,2109887,CDM,272,RC,,,outpatient,,,105.87,63.52,,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,95.28,
CONMED STERLING GREAT WHITE 4.2MM,2109835,CDM,272,RC,,,outpatient,,,382.46,229.48,,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.37,344.21,
CONMED STERLING GREAT WHITE 9299A,2109885,CDM,272,RC,,,outpatient,,,114.79,68.87,,86.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.52,103.31,
CONMED STERLING SPHER BURR 4.5 H9111,2109882,CDM,272,RC,,,outpatient,,,105.87,63.52,,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,95.28,
CONMED SUTURE 2 CIR,2109881,CDM,272,RC,,,outpatient,,,264.8,158.88,,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,238.32,
CONMED SUTURE WHITE H5000,2109880,CDM,272,RC,,,outpatient,,,154.47,92.68,,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,139.02,
CONMED TUBING HAND PC CD8300,2112831,CDM,272,RC,,,outpatient,,,184.13,110.48,,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.73,165.72,
CONVADERM 4X4,2102642,CDM,272,RC,,,outpatient,,,8.2,4.92,,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.68,7.38,
CONVADERM PLUS 6X6,2102643,CDM,272,RC,,,outpatient,,,9.45,5.67,,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.94,8.51,
COOK AMPLATZ STIFF WIRE GUIDE G27032,2112318,CDM,272,RC,,,outpatient,,,142.6,85.56,,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,89.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.22,128.34,
COOK ANGLED CATH 280514,2109599,CDM,272,RC,,,outpatient,,,441.33,264.8,,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,397.2,
COOK ANGLED CATH 280540,2109600,CDM,272,RC,,,outpatient,,,441.33,264.8,,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.43,397.2,
COOK CO 2 CARTRIDGE,2111878,CDM,272,RC,,,outpatient,,,83.07,49.84,,62.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.02,74.76,
COOK CONE TIP CATH 4.8F G14717,2111854,CDM,272,RC,,,outpatient,,,77.58,46.55,,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.9,69.82,
COOK CRICO THYROTOMY CATH SET 16FR,2102823,CDM,272,RC,,,outpatient,,,945.49,567.29,,709.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,756.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,709.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,850.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,709.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,709.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,595.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.73,850.94,
COOK CRICO THYROTOMY CATH SET 18FR,2102824,CDM,272,RC,,,outpatient,,,393.11,235.87,,294.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,294.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,353.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,294.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,247.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.55,353.8,
COOK CRICO THYROTOMY CATH SET 26FR,2102825,CDM,272,RC,,,outpatient,,,865.27,519.16,,648.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,184.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,648.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,778.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,648.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,648.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,545.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.29,778.74,
COOK DILATOR 10FR/20C G00993,2112320,CDM,272,RC,,,outpatient,,,46.44,27.86,,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,41.8,
COOK DILATOR 10X20 JCD 10.0-38-20,2109474,CDM,272,RC,,,outpatient,,,47.1,28.26,,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,42.39,
COOK DILATOR 12X20 JCD 12.0-38-20,2109475,CDM,272,RC,,,outpatient,,,47.1,28.26,,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,42.39,
COOK DILATOR 14X20 JCD 14.0-38-20,2109476,CDM,272,RC,,,outpatient,,,47.1,28.26,,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,42.39,
COOK DILATOR 16X20 JCD 16.0-38-20,2109477,CDM,272,RC,,,outpatient,,,47.1,28.26,,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,42.39,
COOK DILATOR 5X20 JCD 5.0-35-20,2109470,CDM,272,RC,,,outpatient,,,38.51,23.11,,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,34.66,
COOK DILATOR 6X20 JCD 6.0-35-20,2109471,CDM,272,RC,,,outpatient,,,38.51,23.11,,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,34.66,
COOK DILATOR 7X20 JCD 7.0-35-20,2109472,CDM,272,RC,,,outpatient,,,38.51,23.11,,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,34.66,
COOK DILATOR 8FR/20C G00980,2112319,CDM,272,RC,,,outpatient,,,46.44,27.86,,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,41.8,
COOK DILATOR 8X20 JCD 8.0-35-20,2109473,CDM,272,RC,,,outpatient,,,38.51,23.11,,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,34.66,
COOK DOUBLE LUMEN CVL 4.0 F,2102136,CDM,272,RC,,,outpatient,,,542.44,325.46,,406.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,406.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,406.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.15,488.2,
COOK FEMORAL ART. TRAY CMPS300JFA,2109250,CDM,272,RC,,,outpatient,,,283.26,169.96,,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,178.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.04,254.93,
COOK FLEXOR URET ACCESS SHEATH G19172,2111888,CDM,272,RC,,,outpatient,,,282.42,169.45,,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,177.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.87,254.18,
COOK FLEXOR URET ACCESS SHIELD G19168,2111856,CDM,272,RC,,,outpatient,,,362.83,217.7,,272.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,272.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,272.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,228.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.34,326.55,
COOK FUHRMAN PLURAL DRAINAGE SET,2102132,CDM,272,RC,,,outpatient,,,441.76,265.06,,331.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.52,397.58,
COOK HI WIRE GUIDE 3X150 G30476,2111855,CDM,272,RC,,,outpatient,,,99.62,59.77,,74.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.41,89.66,
COOK HOL LASER FIBER 273um G48614,2111963,CDM,272,RC,,,outpatient,,,888.4,533.04,,666.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,710.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,666.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,666.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,666.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,559.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.03,799.56,
COOK HOL LASER FIBER 365um G48616,2111906,CDM,272,RC,,,outpatient,,,871.64,522.98,,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,784.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,549.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.6,784.48,
COOK INTRAOSSCOS NEEDLE 14G,2108825,CDM,272,RC,,,outpatient,,,191.78,115.07,,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.3,172.6,
COOK INTRAOSSCOS NEEDLE 16G,2102139,CDM,272,RC,,,outpatient,,,225.65,135.39,,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.24,203.09,
COOK INTRAOSSCOS NEEDLE 18G,2102140,CDM,272,RC,,,outpatient,,,225.65,135.39,,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.24,203.09,
COOK LASER FIBER MULTI USE 365 FIBER,2111958,CDM,272,RC,,,outpatient,,,968.28,580.97,,726.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,774.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,206.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,726.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,726.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,610.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.4,871.45,
COOK LASER FIBER MULTI USE 940 FIBER,2111959,CDM,272,RC,,,outpatient,,,1851.69,1111.01,,1388.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1481.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,394.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,394.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1388.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,398.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1666.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1388.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1388.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1388.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1388.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1166.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.41,1666.52,
COOK LASER FIBER SINGLE USE HOLMIUM,2111957,CDM,272,RC,,,outpatient,,,1362.62,817.57,,1021.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1090.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,290.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,290.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1021.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1226.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1021.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1021.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1021.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1021.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,858.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.2,1226.36,
COOK N CIRCLE MODIFIED BASKET G18777,2111857,CDM,272,RC,,,outpatient,,,553.47,332.08,,415.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,415.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,498.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,415.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,415.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,348.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.41,498.12,
COOK N GUAGE EXTRACTOR G48294,2111858,CDM,272,RC,,,outpatient,,,614.9,368.94,,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,553.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,387.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.99,553.41,
COOK N TRAP G32724,2111978,CDM,272,RC,,,outpatient,,,672.02,403.21,,504.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,504.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,604.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,504.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,504.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,423.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.7,604.82,
COOK NESTER EMB COILS G26994,2109544,CDM,272,RC,,,outpatient,,,621.9,373.14,,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,497.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,559.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,391.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,559.71,
COOK OASIS 7X10 MESHED WOUND MATRX,2108901,CDM,272,RC,,,outpatient,,,978.57,587.14,,733.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,782.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,208.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,733.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,880.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,733.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,733.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,733.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,733.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,616.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.51,880.71,
COOK OLCOTT TORQUE DEVICE OTD-100,2109569,CDM,272,RC,,,outpatient,,,68.3,40.98,,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,61.47,
COOK PERC. TRACH KIT,2102859,CDM,272,RC,,,outpatient,,,907.51,544.51,,680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,193.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,816.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,571.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.95,816.76,
COOK RABINOV SIALOGRAPHY CATH G01322,2110702,CDM,272,RC,,,outpatient,,,235.42,141.25,,176.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,148.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.24,211.88,
COOK ROADRUNNER G07914,2109469,CDM,272,RC,C1769,HCPCS,outpatient,,,272.55,163.53,,204.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,204.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,204.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,171.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.85,245.3,
COOK ROADRUNNER PC WIRE GUIDE RPC-35-145,2109468,CDM,272,RC,C1769,HCPCS,outpatient,,,297.77,178.66,,223.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,267.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,223.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.01,267.99,
COOK ROADRUNNER PC WIRE GUIDE RPC-35-180,2110595,CDM,272,RC,C1769,HCPCS,outpatient,,,89.96,53.98,,67.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.43,80.96,
COOK ROADRUNNER PC WIRE GUIDE RPC-35-260,2109663,CDM,272,RC,C1769,HCPCS,outpatient,,,335.35,201.21,,251.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,251.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,251.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.71,301.82,
COOK RUSSELL GAS TRAY C-GASTY-1700-RFS,2109530,CDM,272,RC,C1769,HCPCS,outpatient,,,390.63,234.38,,292.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,292.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,292.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.04,351.57,
COOK SINGLE LUMEN CVL 3.0F,2102137,CDM,272,RC,,,outpatient,,,330.9,198.54,,248.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.8,297.81,
COOK STAMEY CATH 12F G14184,2111849,CDM,272,RC,,,outpatient,,,167.74,100.64,,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.37,150.97,
COOK STAMEY CATH 14F G55824,2111850,CDM,272,RC,,,outpatient,,,199.7,119.82,,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.92,179.73,
COOK STONEBREAKER PROBE,2111877,CDM,272,RC,,,outpatient,,,453.85,272.31,,340.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,408.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,340.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,285.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.99,408.47,
COOK SURGISIS 259027,2108940,CDM,272,RC,,,outpatient,,,1681.42,1008.85,,1261.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1345.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,358.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,358.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1261.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1513.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1261.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1059.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.52,1513.28,
COOK SURGISIS C-SLH-4S-7X10,2108980,CDM,272,RC,,,outpatient,,,1293.34,776,,970.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1034.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,275.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,970.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1164.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,970.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,970.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,970.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,970.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,814.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.01,1164.01,
COOK TORNADO EMB COIL G10411,2109542,CDM,272,RC,,,outpatient,,,651.61,390.97,,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,586.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,410.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.51,586.45,
COOK TORNADO EMB COIL G10415,2109630,CDM,272,RC,,,outpatient,,,199.55,119.73,,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.89,179.6,
COOK TOTAL ABSCESSION 10X30,2112321,CDM,272,RC,,,outpatient,,,179.49,107.69,,134.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.78,161.54,
COOK TOTAL ABSCESSION 8X30,2112329,CDM,272,RC,,,outpatient,,,164.34,98.6,,123.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,103.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.67,147.91,
COOK TRIPLE LUMEN CVL 7.0 F,2102134,CDM,272,RC,,,outpatient,,,546.09,327.65,,409.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,409.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,344.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.89,491.48,
COOK WIRE GUIDE 233963,2109467,CDM,272,RC,C1769,HCPCS,outpatient,,,184.17,110.5,,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.74,165.75,
COOPER LONE STAR 12MM ELAS STAYS33508G,2111222,CDM,272,RC,,,outpatient,,,92.72,55.63,,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,83.45,
COOPER LONE STAR 5MM ELAS STAYS33118G,2111223,CDM,272,RC,,,outpatient,,,92.72,55.63,,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,83.45,
COOPER LONE STAR RETRACTOR3304G,2111221,CDM,272,RC,,,outpatient,,,92.72,55.63,,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19,83.45,
CORD CLAMP REMOVER CTR300,2110210,CDM,272,RC,,,outpatient,,,7.65,4.59,,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,6.89,
CORDIS 9FR INT 402-609X,2109547,CDM,272,RC,C1894,HCPCS,outpatient,,,136.11,81.67,,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,122.5,
CORDIS INTRODUCER 6FR 402-606P,2109492,CDM,272,RC,C1894,HCPCS,outpatient,,,136.11,81.67,,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,122.5,
CORDIS INTRODUCER 7FR 402-607P,2109493,CDM,272,RC,C1894,HCPCS,outpatient,,,136.11,81.67,,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.89,122.5,
CORDIS INTRODUCER 8FR 401-805M,2109494,CDM,272,RC,C1894,HCPCS,outpatient,,,264.8,158.88,,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,238.32,
COV 45MM BLUE RELOAD 030455,2112297,CDM,272,RC,,,outpatient,,,503.47,302.08,,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,453.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,317.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,453.12,
COV 45MM PURPLE RELOAD EGIA45AMT,2112903,CDM,272,RC,,,outpatient,,,503.47,302.08,,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,453.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,317.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,453.12,
COV 60MM BLUE RELOAD 030458,2112296,CDM,272,RC,,,outpatient,,,503.47,302.08,,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,453.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,317.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.16,453.12,
COV CEEA 25 4.8 EEAXL25,2101148,CDM,272,RC,,,outpatient,,,1360.72,816.43,,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,289.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1224.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,857.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,1224.65,
COV CEEA 28 4.8 EEAXL28,2112487,CDM,272,RC,,,outpatient,,,1360.72,816.43,,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,289.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1224.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,857.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,1224.65,
COV CEEA 31 4.8 EEAXL31,2112488,CDM,272,RC,,,outpatient,,,1360.72,816.43,,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,289.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1224.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,857.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,1224.65,
COV CEEA 4.8 EEAXL33,2112489,CDM,272,RC,,,outpatient,,,1360.72,816.43,,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1088.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,289.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1224.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,857.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.81,1224.65,
COV CLIP APPLIER 5MM 176630,2108562,CDM,272,RC,,,outpatient,,,1169.49,701.69,,877.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,935.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,249.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,877.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1052.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,877.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,877.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,877.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,877.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,736.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.63,1052.54,
COV DGIA 60 3.8 RELOAD GIA6038L,2111115,CDM,272,RC,,,outpatient,,,490.91,294.55,,368.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,368.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.59,441.82,
COV DGIA 60 3.8 TITANIUM GIA6038S,2101150,CDM,272,RC,,,outpatient,,,921.98,553.19,,691.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,737.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,691.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,829.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,691.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,580.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.91,829.78,
COV EEA 28 4.8 EEA28,2112305,CDM,272,RC,,,outpatient,,,741.96,445.18,,556.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,593.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,158.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,556.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,556.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,467.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.03,667.76,
COV EEA 28 STAPLER EEA283.5,2112327,CDM,272,RC,,,outpatient,,,757.81,454.69,,568.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,606.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,161.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,568.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,682.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,568.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,477.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.28,682.03,
COV ENDO CATCH 10MM 173050G,2103241,CDM,272,RC,,,outpatient,,,1102.56,661.54,,826.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,882.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,234.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,826.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,992.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,826.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,826.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,826.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,826.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,694.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.91,992.3,
COV ENDO CLIP II M-L*,2103270,CDM,272,RC,,,outpatient,,,450.76,270.46,,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,283.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.36,405.68,
COV ENDO GIA 12MM UNIV INST 030449,2112291,CDM,272,RC,,,outpatient,,,248.04,148.82,,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.82,223.24,
COV ENDO GIA 12MM UNIV INST EGIAUSTND,2112892,CDM,272,RC,,,outpatient,,,248.04,148.82,,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.82,223.24,
COV ENDO GIA 45 2.0 EGIA45AV,2112290,CDM,272,RC,,,outpatient,,,505.39,303.23,,379.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,379.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,379.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,318.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.55,454.85,
COV ENDO GIA 45 2.5 030454,2112289,CDM,272,RC,,,outpatient,,,431.63,258.98,,323.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,323.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,323.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,271.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.44,388.47,
COV ENDO GIA 45 EGIA45AVM,2112873,CDM,272,RC,,,outpatient,,,464.62,278.77,,348.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.2,418.16,
COV ENDO GIA 60 2.5 RELOAD 030457,2112420,CDM,272,RC,,,outpatient,,,977.72,586.63,,733.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,782.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,208.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,733.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,879.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,733.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,733.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,733.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,733.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,615.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.33,879.95,
COV ENDO GIA U SHORT 030403,2112300,CDM,272,RC,,,outpatient,,,227.57,136.54,,170.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,170.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.63,204.81,
COV ENDO HANDLE 03449,2112295,CDM,272,RC,,,outpatient,,,247.78,148.67,,185.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,185.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.77,223,
COV LAP DEVI LIG MARYL JAW 5MM,2112527,CDM,272,RC,,,outpatient,,,1220.58,732.35,,915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1098.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,768.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.1,1098.52,
COV NEEDLE VERES 172015,2102597,CDM,272,RC,,,outpatient,,,509.49,305.69,,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,407.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,320.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,458.54,
COV NEEDLE VERES LONG 172016,2112410,CDM,272,RC,,,outpatient,,,509.49,305.69,,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,407.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,320.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,458.54,
COV RELOAD 90 3.5 TA9035L,2112494,CDM,272,RC,,,outpatient,,,216.36,129.82,,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,136.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.33,194.72,
COV RELOAD STPLR TA6048L,2101978,CDM,272,RC,,,outpatient,,,860.52,516.31,,645.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,688.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,645.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,774.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,645.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,542.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.32,774.47,
COV RELOAD TA30 4.8 TA3048L,2109843,CDM,272,RC,,,outpatient,,,222.38,133.43,,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,140.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.57,200.14,
COV RELOAD TA60 3.5 TA6035L,2109841,CDM,272,RC,,,outpatient,,,237.94,142.76,,178.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,149.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.75,214.15,
COV ROTICULATOR 55-4.8 017614,2102668,CDM,272,RC,,,outpatient,,,1540.75,924.45,,1155.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1232.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,328.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,328.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1155.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1386.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1155.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,970.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.7,1386.68,
COV SKIN STAPLER 8886803712,2103253,CDM,272,RC,,,outpatient,,,421.27,252.76,,315.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,315.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,315.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,379.14,
COV SLEEVE 12MM ONBFCA12ST(co652,2109772,CDM,272,RC,,,outpatient,,,149.7,89.82,,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.67,134.73,
COV STAPLER 60 3.5TA6035S,2112310,CDM,272,RC,,,outpatient,,,214.99,128.99,,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,135.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.05,193.49,
COV STAPLR GIA6048S,2101153,CDM,272,RC,,,outpatient,,,237.28,142.37,,177.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,177.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,177.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,149.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.62,213.55,
COV STPLR 60 4.8 TA6048S,2112309,CDM,272,RC,,,outpatient,,,891.16,534.7,,668.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,668.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,802.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,668.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,668.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,668.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,668.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,561.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.6,802.04,
COV STPLR DGIA 60 RELOADER,2102400,CDM,272,RC,,,outpatient,,,1129.6,677.76,,847.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,903.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,847.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1016.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,847.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,711.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.46,1016.64,
COV STPLR RELOAD TA90 4.8 TA9048L,2109840,CDM,272,RC,,,outpatient,,,247.51,148.51,,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.71,222.76,
COV STPLR ROTICULATOR 90 3.5 TA9035S,2112268,CDM,272,RC,,,outpatient,,,1495.94,897.56,,1121.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1196.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,318.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,318.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1121.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1346.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1121.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1121.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1121.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1121.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,942.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,306.52,1346.35,
COV STPLR TA3035L,2110622,CDM,272,RC,,,outpatient,,,228.93,137.36,,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,144.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.91,206.04,
COV STPLR TA55 TA5535S,2101154,CDM,272,RC,,,outpatient,,,381.71,229.03,,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.21,343.54,
COV STPLR TA90 4.8MM TA9048S,2101151,CDM,272,RC,,,outpatient,,,641.98,385.19,,481.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,481.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,577.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,481.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,481.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,481.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,481.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,404.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.54,577.78,
COV SURGICLIP 11.5 MED 134053,2102209,CDM,272,RC,,,outpatient,,,1023.88,614.33,,767.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,218.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,767.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,921.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,767.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,645.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.79,921.49,
COV SURGICLIP 13.0 LARGE 134048,2102186,CDM,272,RC,,,outpatient,,,1103.38,662.03,,827.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,882.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,827.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,993.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,827.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,695.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.08,993.04,
COV SURGICLIP 9.0 SMALL,2102699,CDM,272,RC,,,outpatient,,,1047.92,628.75,,785.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,785.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,943.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,785.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,785.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,785.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,785.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,660.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.72,943.13,
COV SURGICLIP MEDIUM 11.5 134053,2100396,CDM,272,RC,,,outpatient,,,1048.48,629.09,,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,943.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,660.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.83,943.63,
COV TA3048S,2102459,CDM,272,RC,,,outpatient,,,905.43,543.26,,679.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,679.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,814.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,679.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,679.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,679.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,679.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,570.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.52,814.89,
COV TACKER ABSTACK15X,2112301,CDM,272,RC,,,outpatient,,,1135.35,681.21,,851.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,908.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,851.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1021.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,851.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,851.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,715.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.63,1021.82,
COV TACKER ABSTACK30X,2112276,CDM,272,RC,,,outpatient,,,1130.69,678.41,,848.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,848.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1017.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,848.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,712.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.68,1017.62,
COV TROCAR 10/12MM BLU BPT12STS,2102857,CDM,272,RC,,,outpatient,,,421.8,253.08,,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,379.62,
COV TROCAR 12MM BLUNT,2113004,CDM,272,RC,,,outpatient,,,421.8,253.08,,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,379.62,
COV TROCAR 12MM LONG BLADED B12LGF,2112412,CDM,272,RC,,,outpatient,,,421.8,253.08,,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,379.62,
COV TROCAR 5 BLADED B5STF,2112345,CDM,272,RC,,,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,120.23,
COV TROCAR 5MM LONG NO BLADE ONB5LGF,2112411,CDM,272,RC,,,outpatient,,,421.8,253.08,,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.43,379.62,
COV TROCAR 5MM ONB5STF,2111315,CDM,272,RC,,,outpatient,,,269.09,161.45,,201.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.14,242.18,
COV TROCAR 5MM Sl ONBFCA5ST(cts02,2111316,CDM,272,RC,,,outpatient,,,66.12,39.67,,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,59.51,
COV TROCAR BLA 179096PF R,2112470,CDM,272,RC,,,outpatient,,,274,164.4,,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,172.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.14,246.6,
COV TROCAR BLADED10/12MM B12STF,2102629,CDM,272,RC,,,outpatient,,,274,164.4,,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,172.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.14,246.6,
COV TROCAR BLADELES12MM ONB12STF,2112304,CDM,272,RC,,,outpatient,,,120.51,72.31,,90.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,108.46,
CR BARD 38CM 20-QRINGS 0113035,2109562,CDM,272,RC,,,outpatient,,,845.22,507.13,,633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,532.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.19,760.7,
CR BARD IMPLANT 180CM 10-ORINGS 0113043,2109564,CDM,272,RC,,,outpatient,,,406.01,243.61,,304.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,304.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,365.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,304.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,255.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.19,365.41,
CR BARD IMPLANT 38CM 50-ORINGS 0113059,2109563,CDM,272,RC,,,outpatient,,,1599.84,959.9,,1199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1439.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1199.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1007.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,327.81,1439.86,
CROZIER COLD THERAPY PAD 1112US,2109908,CDM,272,RC,,,outpatient,,,300.5,180.3,,225.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,225.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.57,270.45,
CROZIER PROTECTIVE PAD 294P,2109904,CDM,272,RC,,,outpatient,,,281.39,168.83,,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,177.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,253.25,
CURETTE 10MM STRAIGHT UTERINE,2108608,CDM,272,RC,,,outpatient,,,23.76,14.26,,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,21.38,
CURETTE 8MM CURVED UTERINE 280,2108607,CDM,272,RC,,,outpatient,,,25.95,15.57,,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,23.36,
CURETTE CHESHIRE 6 inch STRAIGHT,2109201,CDM,272,RC,,,outpatient,,,8.81,5.29,,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,7.93,
CURETTE CHESHIRE 6MM CURVED,2108632,CDM,272,RC,,,outpatient,,,9.87,5.92,,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,8.88,
CURETTE VACCUUM 12MM CURVED 284,2108892,CDM,272,RC,,,outpatient,,,22.95,13.77,,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.7,20.66,
CUTDOWN TRAY,2100337,CDM,272,RC,,,outpatient,,,57.82,34.69,,43.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.85,52.04,
CYSTO SET,2100389,CDM,272,RC,,,outpatient,,,57.37,34.42,,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.76,51.63,
CYSTOSOPY TRAY,2100326,CDM,272,RC,,,outpatient,,,119.36,71.62,,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,107.42,
DAIG VESSEL DILATOR 14F 405536,2109484,CDM,272,RC,,,outpatient,,,33.85,20.31,,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,30.47,
DAIG VESSEL DILATOR 16F 405544,2109485,CDM,272,RC,,,outpatient,,,33.85,20.31,,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.94,30.47,
DALE O2 CANNULA HOLDER,2108548,CDM,272,RC,,,outpatient,,,19.67,11.8,,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,17.7,
DALE TRACH TUBE HOLDER H84102401,2108549,CDM,272,RC,,,outpatient,,,49.45,29.67,,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,44.51,
DATASCOPE PROGUIDE 14.5 61136,2109668,CDM,272,RC,C1750,HCPCS,outpatient,,,662,397.2,,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,417.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,595.8,
DATASCOPE PROGUIDE 24CM,2109628,CDM,272,RC,C1750,HCPCS,outpatient,,,662,397.2,,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,417.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,595.8,
DATASCOPE PROGUIDE 28CM 61128,2109624,CDM,272,RC,C1750,HCPCS,outpatient,,,662,397.2,,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,417.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,595.8,
DATASCOPE PROGUIDE 32CM 61132,2109625,CDM,272,RC,C1750,HCPCS,outpatient,,,662,397.2,,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,417.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,595.8,
DATASCOPE PROGUIDE 40CM 61140,2109642,CDM,272,RC,C1750,HCPCS,outpatient,,,662,397.2,,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,417.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.64,595.8,
DATASCOPE PROLUMEN THROMB DEVICE 86311,2109627,CDM,272,RC,,,outpatient,,,1213.67,728.2,,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,970.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1092.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,764.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.68,1092.3,
DATASCOPE SAFEGUARD 12CM 82050,2109626,CDM,272,RC,,,outpatient,,,367.81,220.69,,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,331.03,
DATASCOPE SAFEGUARD 82000D,2109585,CDM,272,RC,,,outpatient,,,434.01,260.41,,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,273.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.93,390.61,
DAVOL SIMPULSE SOLO,2103027,CDM,272,RC,,,outpatient,,,526.63,315.98,,394.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,394.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,473.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,394.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,331.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.91,473.97,
DAVOL SIMPULSE SPLASH GUARD 4 in 0037630,2111066,CDM,272,RC,,,outpatient,,,38.51,23.11,,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,34.66,
DAVOL SIMPULSE SPLASH GUARD 9 inch,2103076,CDM,272,RC,,,outpatient,,,119.04,71.42,,89.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.39,107.14,
DELEE MUCOUS TRAP,2102652,CDM,272,RC,,,outpatient,,,49.73,29.84,,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.19,44.76,
DEP MITEK SUPER BONE ANCHORS 4 PRONG,2108794,CDM,272,RC,,,outpatient,,,577.97,346.78,,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,364.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.43,520.17,
DEPUY FACESHIELD STD 5408-20-000,2109858,CDM,272,RC,,,outpatient,,,116.93,70.16,,87.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.96,105.24,
DEPUY SMALL BONE FIXATION 1.6 SBFS062,2110412,CDM,272,RC,,,outpatient,,,650.97,390.58,,488.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,488.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,585.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,488.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,410.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.38,585.87,
DERMA BOND PRO PEN,2109319,CDM,272,RC,,,outpatient,,,661.26,396.76,,495.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,495.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,595.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,495.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,416.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.49,595.13,
DERMATOME BLADE CUTTING HEAD CH,2112302,CDM,272,RC,,,outpatient,,,210.36,126.22,,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,132.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.1,189.32,
DERMOSTRIP,2101175,CDM,272,RC,,,outpatient,,,256.51,153.91,,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,161.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.56,230.86,
DEXTERITY PROTRACTOR SMALL 100101,2108808,CDM,272,RC,,,outpatient,,,892.86,535.72,,669.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,714.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,190.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,669.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,803.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,669.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,669.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,562.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.95,803.57,
DIAGS PACEMAKER TEMP 401775,2108996,CDM,272,RC,,,outpatient,,,258.64,155.18,,193.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,193.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,193.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,162.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53,232.78,
DIAL A FLO W/LEUR LOK 2C6891,2100449,CDM,272,RC,,,outpatient,,,89.33,53.6,,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.3,80.4,
DOBBHOFF FEEDING TUBE 12F,2102730,CDM,272,RC,,,outpatient,,,189.05,113.43,,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,119.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.74,170.15,
DRAIN SILASTIC THORACIC,2101788,CDM,272,RC,,,outpatient,,,187.68,112.61,,140.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,140.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,118.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.46,168.91,
DRESSING IV CATH SECUREMENT*,2112405,CDM,272,RC,,,outpatient,,,1.03,0.62,,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,0.93,
DUCKBILL VESSEL 30001,2102969,CDM,272,RC,,,outpatient,,,52.62,31.57,,39.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.78,47.36,
DUDODERM 6X6CGF,2103052,CDM,272,RC,,,outpatient,,,232.02,139.21,,174.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,146.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.54,208.82,
DUO-FLOW CATH DFXL146IJS,2109084,CDM,272,RC,,,outpatient,,,301.83,181.1,,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,190.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.84,271.65,
DUO-FLOW CATH DFXL146MTY,2109082,CDM,272,RC,,,outpatient,,,289.95,173.97,,217.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,217.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,217.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.41,260.96,
DUO-FLOW CATH DFXL148IJS,2109085,CDM,272,RC,,,outpatient,,,301.83,181.1,,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,190.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.84,271.65,
DUODERM 2X4 1638187900,2109511,CDM,272,RC,,,outpatient,,,16.12,9.67,,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.3,14.51,
DUODERM 2X8,2109353,CDM,272,RC,,,outpatient,,,30.34,18.2,,22.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.22,27.31,
DUODERM 4X4 187955,2109632,CDM,272,RC,,,outpatient,,,15.7,9.42,,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,14.13,
DUODERM 4X4 W/CGF BORDER,2103013,CDM,272,RC,,,outpatient,,,65.67,39.4,,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.46,59.1,
DUODERM 6X7CGF 1638187974,2109512,CDM,272,RC,,,outpatient,,,100.26,60.16,,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,63.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,90.23,
DUODERM 6X8 1638187643,2111374,CDM,272,RC,,,outpatient,,,49.99,29.99,,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,44.99,
DUODERM SPOT,2108789,CDM,272,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
DURA PREP SOL 26ML,2102660,CDM,272,RC,,,outpatient,,,72.4,43.44,,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,65.16,
EAR SYR 2 OZ,2100217,CDM,272,RC,,,outpatient,,,37.43,22.46,,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,33.69,
ELECTRODE FETAL MONITORING PAD 2464AAO,2103004,CDM,272,RC,,,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,8.12,
ELECTRODE SPIRAL,2101166,CDM,272,RC,,,outpatient,,,99.71,59.83,,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,89.74,
ENDO PEANUT 173019,2108812,CDM,272,RC,,,outpatient,,,547.73,328.64,,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,345.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.23,492.96,
ENDO RETRACT II 176647,2109060,CDM,272,RC,,,outpatient,,,271.69,163.01,,203.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,203.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,171.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.67,244.52,
ENDO TUBE 0 12-100382020,2101299,CDM,272,RC,,,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
ENDO TUBE 2.5 12-100382025 (NURSERY),2102160,CDM,272,RC,,,outpatient,,,22.13,13.28,,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,19.92,
ENDO TUBE 3.0 12-100380030 (ANES),2111685,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 3.0 12-100382030 (NURSERY),2101283,CDM,272,RC,,,outpatient,,,23.23,13.94,,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.91,
ENDO TUBE 3.5 12-100380035 (ANES),2111875,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 3.5 12-100382035 (NURSERY),2101577,CDM,272,RC,,,outpatient,,,18.85,11.31,,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,16.97,
ENDO TUBE 4.0 12-100382040 (ANES),2111686,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 4.0 ARGYLE,2102159,CDM,272,RC,,,outpatient,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,24.59,
ENDO TUBE 4.0 CUFFED NEW (ANES,2112430,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 4.5 12-100382045 (ANES),2111687,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 4.5 12-112480045 (NURSERY),2101581,CDM,272,RC,,,outpatient,,,39.06,23.44,,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,35.15,
ENDO TUBE 4.5 CUFFED NEW (ANES,2112431,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 4.5 UNCUFFED,2108722,CDM,272,RC,,,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,12.54,
ENDO TUBE 5.0 CUFFED NEW (ANES,2112432,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 5.0 SOURCEMARK,2111688,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 5.5 ANES,2101300,CDM,272,RC,,,outpatient,,,20.22,12.13,,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,18.2,
ENDO TUBE 5.5 CUFFED NEW (ANES,2112433,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
ENDO TUBE 6.5 SOURCE MARK,2101301,CDM,272,RC,,,outpatient,,,25.41,15.25,,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,22.87,
ENDO TUBE 7.0,2100206,CDM,272,RC,,,outpatient,,,32.67,19.6,,24.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,29.4,
ENDO TUBE 7.0 SOURCE MARK,2111835,CDM,272,RC,,,outpatient,,,20.6,12.36,,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.54,
ENDO TUBE 7.5,2100207,CDM,272,RC,,,outpatient,,,25.25,15.15,,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,22.73,
ENDO TUBE 7.5 SOURCE MARK,2111838,CDM,272,RC,,,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,13.91,
ENDO TUBE 8.0 M0480C,2100208,CDM,272,RC,,,outpatient,,,31.15,18.69,,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,28.04,
ENDO TUBE 9.5,2101302,CDM,272,RC,,,outpatient,,,25.41,15.25,,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,22.87,
ENDO TUBE MALLINCODT 6MM,2108446,CDM,272,RC,,,outpatient,,,116.17,69.7,,87.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.8,104.55,
ENDO TUBE MALLINCRODT 4MM,2108448,CDM,272,RC,,,outpatient,,,127.03,76.22,,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.03,114.33,
ENDO TUBES 10,2101303,CDM,272,RC,,,outpatient,,,28.33,17,,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,25.5,
ENDOCLOSE 173022,2103350,CDM,272,RC,,,outpatient,,,353.51,212.11,,265.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,265.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,318.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,265.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,222.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.43,318.16,
ENSURE DRESS 4X 5 1/2,2102457,CDM,272,RC,,,outpatient,,,15.59,9.35,,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,14.03,
ENSURE DRESSING,2102469,CDM,272,RC,,,outpatient,,,5.52,3.31,,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.13,4.97,
ENTERNAL FEEDING CONT,2100230,CDM,272,RC,,,outpatient,,,21.03,12.62,,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,18.93,
ESCHMANN TRACHEAL INTRODUCER,2109190,CDM,272,RC,,,outpatient,,,367.81,220.69,,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,331.03,
ESOPHOGEAL STETHESCOPE SONOTEMP 18F,2101332,CDM,272,RC,,,outpatient,,,38.09,22.85,,28.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,34.28,
ETHICON 35W SKIN STAPLER,2113251,CDM,272,RC,,,outpatient,,,28.43,17.06,,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,25.59,
ETHICON APR VAS CUTTER 55MM TVC55,2112638,CDM,272,RC,,,outpatient,,,198.39,119.03,,148.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,124.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.65,178.55,
ETHICON CLIP APPLIER EL5ML,2110704,CDM,272,RC,,,outpatient,,,886.07,531.64,,664.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,664.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,797.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,664.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,664.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,664.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,664.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,558.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.56,797.46,
ETHICON DERMABOND DB12,2108754,CDM,272,RC,,,outpatient,,,182.69,109.61,,137.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,115.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.43,164.42,
ETHICON ECS21,2102035,CDM,272,RC,,,outpatient,,,1690.33,1014.2,,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,360.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1521.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1064.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,1521.3,
ETHICON ECS25,2102033,CDM,272,RC,,,outpatient,,,1690.33,1014.2,,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,360.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1521.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1064.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,1521.3,
ETHICON ECS33,2101072,CDM,272,RC,,,outpatient,,,1690.33,1014.2,,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,360.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1521.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1064.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.35,1521.3,
ETHICON ENDOANCHOR EANCHR5,2109268,CDM,272,RC,,,outpatient,,,1003.61,602.17,,752.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,802.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,752.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,903.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,752.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,752.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,752.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,752.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,632.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.64,903.25,
ETHICON ENDOCLIP MUL CLIP APPLIER ER320,2102570,CDM,272,RC,,,outpatient,,,655.42,393.25,,491.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,491.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,491.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,412.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.3,589.88,
ETHICON ENDOPATH CURVED SCISSORS,2102628,CDM,272,RC,,,outpatient,,,418.53,251.12,,313.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,313.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,376.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,263.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.76,376.68,
ETHICON ETS CUTTER RELOAD TR35B,2111057,CDM,272,RC,,,outpatient,,,175.58,105.35,,131.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,110.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.98,158.02,
ETHICON ETS ENDO CUTTER ATB35,2111056,CDM,272,RC,,,outpatient,,,984.2,590.52,,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,209.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,620.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,885.78,
ETHICON FLAT MESH 12X12 VICRYL VKML,2112529,CDM,272,RC,C1781,HCPCS,outpatient,,,1904.08,1142.45,,1428.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1523.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,405.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1428.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1713.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1428.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1428.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1199.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.15,1713.67,
ETHICON LAP CHOLE KIT FTR32,2103296,CDM,272,RC,,,outpatient,,,1459.58,875.75,,1094.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1167.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,310.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1094.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1313.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1094.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1094.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1094.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1094.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,919.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.07,1313.62,
ETHICON LINEAR 60,2102706,CDM,272,RC,,,outpatient,,,573.1,343.86,,429.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,429.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,515.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,429.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,361.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.43,515.79,
ETHICON LINEAR 60 REFILL,2102707,CDM,272,RC,,,outpatient,,,931.89,559.13,,698.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,745.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,698.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,838.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,698.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,587.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.94,838.7,
ETHICON PROLENE MESH 3X6 PMII,2111465,CDM,272,RC,C1781,HCPCS,outpatient,,,228.38,137.03,,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.8,205.54,
ETHICON PROLENE MESH 6X6,2111412,CDM,272,RC,C1781,HCPCS,outpatient,,,263.62,158.17,,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.02,237.26,
ETHICON REDUCER CAP 1SEAL,2109284,CDM,272,RC,,,outpatient,,,67.26,40.36,,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.78,60.53,
ETHICON REDUCERS MS512,2102577,CDM,272,RC,,,outpatient,,,64.82,38.89,,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,58.34,
ETHICON RELOAD TR35W,2109235,CDM,272,RC,,,outpatient,,,379.38,227.63,,284.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,284.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,284.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.73,341.44,
ETHICON ROTICULATING STPLR,2100608,CDM,272,RC,,,outpatient,,,1241.47,744.88,,931.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,993.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,264.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,931.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1117.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,931.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,931.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,931.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,931.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,782.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.38,1117.32,
ETHICON SKIN STPLR 35W,2101185,CDM,272,RC,,,outpatient,,,610.76,366.46,,458.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,458.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,458.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,384.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.14,549.68,
ETHICON STPLR CDH21,2101649,CDM,272,RC,,,outpatient,,,1132.08,679.25,,849.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,905.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,849.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1018.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,849.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,849.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,713.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.96,1018.87,
ETHICON TROCAR 12 D12LT,2110938,CDM,272,RC,,,outpatient,,,431.15,258.69,,323.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,323.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,323.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,271.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.34,388.04,
ETHICON TROCAR 5MM D5LT,2110937,CDM,272,RC,,,outpatient,,,326.76,196.06,,245.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.95,294.08,
EV3 AMPLATZ GOOSE NECK MICROVENA GN1500,2109491,CDM,272,RC,,,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,546.15,
EV3 AMPLATZ GOOSE NECK SNARE KIT GN1001,2109490,CDM,272,RC,C1773,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,546.15,
EXTERNAL WRIST FIXATOR 04250,2109770,CDM,272,RC,,,outpatient,,,3248.26,1948.96,,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2598.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,691.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,698.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2923.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2046.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.57,2923.43,
EXTRA HAND,2108401,CDM,272,RC,,,outpatient,,,426.48,255.89,,319.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,319.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,268.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.39,383.83,
EYE PAD LG,2109008,CDM,272,RC,,,outpatient,,,1.37,0.82,,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.28,1.23,
EYE PADS,2100524,CDM,272,RC,,,outpatient,,,13.11,7.87,,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,11.8,
EYE PROTECTION SHIELD 1314EP2500,2112241,CDM,272,RC,,,outpatient,,,19.67,11.8,,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,17.7,
FEEDING TUBE 10F 358388260208,2111566,CDM,272,RC,,,outpatient,,,4.92,2.95,,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.01,4.43,
FEEDING TUBE 5F X 16 inch ARGYLE,2101500,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
FEEDING TUBE 5F X 36,2100070,CDM,272,RC,,,outpatient,,,13.67,8.2,,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,12.3,
FEEDING TUBE 5FR /15,2100069,CDM,272,RC,,,outpatient,,,5.09,3.05,,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.04,4.58,
FEEDING TUBE 8F X 16 inch ARGYLE,2101501,CDM,272,RC,,,outpatient,,,8.47,5.08,,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.74,7.62,
FEEDING TUBE 8F X 42,2100068,CDM,272,RC,,,outpatient,,,19.67,11.8,,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,17.7,
FEEDING TUBE ENTRIFLEX 6FR,2112536,CDM,272,RC,,,outpatient,,,87.69,52.61,,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.97,78.92,
FILSHIE CLIPS AVM-851J,2109280,CDM,272,RC,,,outpatient,,,426.58,255.95,,319.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,319.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,268.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.41,383.92,
FOLEY CATH 10FR 3CC,2101730,CDM,272,RC,,,outpatient,,,120.75,72.45,,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,108.68,
FOLEY CATH 10FR 5CC,2100091,CDM,272,RC,,,outpatient,,,58.46,35.08,,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,52.61,
FOLEY CATH 12FR 5CC*,2100090,CDM,272,RC,,,outpatient,,,34.97,20.98,,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,31.47,
FOLEY CATH 14FR SILICONE 5CC,2100045,CDM,272,RC,,,outpatient,,,34.97,20.98,,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,31.47,
FOLEY CATH 16FR 30CC 3WAY,2109053,CDM,272,RC,,,outpatient,,,124.03,74.42,,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.41,111.63,
FOLEY CATH 16FR SILI 5CC,2100093,CDM,272,RC,,,outpatient,,,153.53,92.12,,115.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.46,138.18,
FOLEY CATH 18FR,2100094,CDM,272,RC,,,outpatient,,,50.26,30.16,,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,45.23,
FOLEY CATH 18FR 30CC 2 WAY,2109367,CDM,272,RC,,,outpatient,,,34.69,20.81,,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,31.22,
FOLEY CATH 18FR 30CC 3WAY SILICONE,2101727,CDM,272,RC,,,outpatient,,,51.08,30.65,,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,45.97,
FOLEY CATH 20FR 30CC 3 WAY SILICONE,2100032,CDM,272,RC,,,outpatient,,,51.08,30.65,,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,45.97,
FOLEY CATH 20FR 5CC,2100095,CDM,272,RC,,,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,23.12,
FOLEY CATH 22FR,2100031,CDM,272,RC,,,outpatient,,,24.32,14.59,,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,21.89,
FOLEY CATH 22FR 30CC 3WAY SILICONE,2101075,CDM,272,RC,,,outpatient,,,51.08,30.65,,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,45.97,
FOLEY CATH 22FR 5CC TEFLON,2101749,CDM,272,RC,,,outpatient,,,30.06,18.04,,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,27.05,
FOLEY CATH 22FR SILI 5CC,2100096,CDM,272,RC,,,outpatient,,,56,33.6,,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.47,50.4,
FOLEY CATH 24FR 30CC,2100030,CDM,272,RC,,,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,23.12,
FOLEY CATH 24FR 30CC 3 WAY,2100370,CDM,272,RC,,,outpatient,,,106.81,64.09,,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,96.13,
FOLEY CATH 24FR SILI 5CC,2100097,CDM,272,RC,,,outpatient,,,50.26,30.16,,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,45.23,
FOLEY CATH 26FR 30CC,2101733,CDM,272,RC,,,outpatient,,,68.3,40.98,,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,61.47,
FOLEY CATH 26FR 30CC 3WAY,2102556,CDM,272,RC,,,outpatient,,,47.8,28.68,,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,43.02,
FOLEY CATH 26FR 5CC,2100049,CDM,272,RC,,,outpatient,,,32.51,19.51,,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.66,29.26,
FOLEY CATH 28FR 30CC,2100092,CDM,272,RC,,,outpatient,,,19.67,11.8,,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,17.7,
FOLEY CATH 28FR 5CC,2100050,CDM,272,RC,,,outpatient,,,53.27,31.96,,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.92,47.94,
FOLEY CATH 30FR 30C,2101269,CDM,272,RC,,,outpatient,,,51.63,30.98,,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,46.47,
FOLEY CATH 30FR 30CC TEFLON,2101729,CDM,272,RC,,,outpatient,,,82.5,49.5,,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,74.25,
FOLEY CATH 6FR,2108893,CDM,272,RC,,,outpatient,,,184.39,110.63,,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.78,165.95,
FOLEY CATH 8FR 3CC*,2101696,CDM,272,RC,,,outpatient,,,138.5,83.1,,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.38,124.65,
FORCEP ALLIGATOR JAW 2.8 MM 230CM,2112517,CDM,272,RC,,,outpatient,,,29.5,17.7,,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,26.55,
FORCEP BIOPSY 240CM FB-220U.A,2102553,CDM,272,RC,,,outpatient,,,635.15,381.09,,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,571.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,400.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,571.64,
FORCEP BIOPSY EGD FB-220K.A,2112114,CDM,272,RC,,,outpatient,,,94.76,56.86,,71.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.42,85.28,
FORCEP BIOPSY HOT FD-210U,2112234,CDM,272,RC,,,outpatient,,,89.88,53.93,,67.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.42,80.89,
FORCEP QUICKCLIP PRO 230CM,2112521,CDM,272,RC,,,outpatient,,,356.78,214.07,,267.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,267.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,224.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.1,321.1,
FORCEP SNARE 10MM 230CM,2112518,CDM,272,RC,,,outpatient,,,41.52,24.91,,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,37.37,
FORCEP SNARE 15MM 230CM,2112519,CDM,272,RC,,,outpatient,,,41.52,24.91,,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.51,37.37,
FRAC. PAC SPLINT RENTAL,2102485,CDM,272,RC,,,outpatient,,,43.6,26.16,,32.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.93,39.24,
FURACIN GAUZE,2100416,CDM,272,RC,,,outpatient,,,454.91,272.95,,341.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,341.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.21,409.42,
GAS SAMPLING LINE,2112703,CDM,272,RC,,,outpatient,,,6.18,3.71,,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,5.56,
"GASTROSTOMY TUBE 12FR,LV*",2101176,CDM,272,RC,,,outpatient,,,468.51,281.11,,351.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,351.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,351.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,295.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96,421.66,
GASTROSTOMY TUBE 14FR*,2101178,CDM,272,RC,,,outpatient,,,523.69,314.21,,392.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,392.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,471.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,392.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,329.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.3,471.32,
GASTROSTOMY TUBE 16FR*,2101180,CDM,272,RC,,,outpatient,,,474.52,284.71,,355.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,355.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,355.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,298.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.23,427.07,
GASTROSTOMY TUBE 18FR*,2101181,CDM,272,RC,,,outpatient,,,530.24,318.14,,397.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,397.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,397.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,334.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.65,477.22,
GASTROSTOMY TUBE 20FR*,2101182,CDM,272,RC,,,outpatient,,,479.71,287.83,,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.29,431.74,
GASTROSTOMY TUBE 24FR*,2101184,CDM,272,RC,,,outpatient,,,494.46,296.68,,370.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,370.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,311.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.31,445.01,
GASTROSTOMY TUBE 26FR*,2102279,CDM,272,RC,,,outpatient,,,442.83,265.7,,332.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,332.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,398.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,332.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.74,398.55,
GASTROSTOMY TUBE 28FR*,2102280,CDM,272,RC,,,outpatient,,,492,295.2,,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.81,442.8,
GASTROSTOMY TUBE 30FR*,2102281,CDM,272,RC,,,outpatient,,,538.99,323.39,,404.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,431.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,404.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,404.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,339.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.44,485.09,
GAUZE 4X4 STERILE,2100244,CDM,272,RC,,,outpatient,,,25.75,15.45,,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,23.18,
GELFOAM 100 P9034201P,2102082,CDM,272,RC,,,outpatient,,,250.24,150.14,,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,157.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.27,225.22,
GELFOAM 12-7MM,2102645,CDM,272,RC,,,outpatient,,,51.63,30.98,,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,46.47,
GELFOAM 50 P9032301P,2112723,CDM,272,RC,,,outpatient,,,250.24,150.14,,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,157.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.27,225.22,
GIGLI SAW BLADE 20,2109336,CDM,272,RC,,,outpatient,,,94.74,56.84,,71.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.41,85.27,
GORTEX SUTURE 2N05A,2102584,CDM,272,RC,,,outpatient,,,134.52,80.71,,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,121.07,
GORTEX SUTURE 5M02B,2103182,CDM,272,RC,,,outpatient,,,172.4,103.44,,129.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,108.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.32,155.16,
GORTEX SUTURE 6M02A (1DZ),2111233,CDM,272,RC,,,outpatient,,,173.14,103.88,,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.48,155.83,
GORTEX SUTURE 6M02B,2103014,CDM,272,RC,,,outpatient,,,173.14,103.88,,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.48,155.83,
GORTEX SUTURE 6N16A,2102619,CDM,272,RC,,,outpatient,,,199.13,119.48,,149.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.8,179.22,
GORTEX SUTURE 7M06A,2102618,CDM,272,RC,,,outpatient,,,181.84,109.1,,136.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.26,163.66,
GORTEX SUTURE 8J02A,2109623,CDM,272,RC,,,outpatient,,,155.21,93.13,,116.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.8,139.69,
GORTEX SUTURE 8J02B,2109635,CDM,272,RC,,,outpatient,,,82.97,49.78,,62.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17,74.67,
GRAFT HEMASHIELD 20-10MM-40CM,2102934,CDM,272,RC,,,outpatient,,,2582.39,1549.43,,1936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2065.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,550.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,550.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,555.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2324.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1936.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1626.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.13,2324.15,
GRAFT VASCULAR VENAFLO II VLT4047C,2109767,CDM,272,RC,,,outpatient,,,1803.55,1082.13,,1352.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1442.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,384.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1352.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1623.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1352.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1136.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.55,1623.2,
GROSHONG REPAIR KIT,2101503,CDM,272,RC,,,outpatient,,,92.3,55.38,,69.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.91,83.07,
GUIDELINES LARGE 217,2112347,CDM,272,RC,,,outpatient,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,43.52,
GUIDEWIRE BOWL DYNJGUIDEWIRE,2112171,CDM,272,RC,,,outpatient,,,22.4,13.44,,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.16,
GYRUS PK BUTTON 786500,2111859,CDM,272,RC,,,outpatient,,,1129.96,677.98,,847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,903.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1016.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,711.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.53,1016.96,
GYRUS PK LOOP ELECTRODE 784415,2111860,CDM,272,RC,,,outpatient,,,1076.17,645.7,,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,968.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,677.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.51,968.55,
GYRUS PK SUPERSECT 784515,2111861,CDM,272,RC,,,outpatient,,,1076.17,645.7,,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,968.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,677.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.51,968.55,
HEIMLICH CHEST DRAIN VALVE,2103090,CDM,272,RC,,,outpatient,,,174.02,104.41,,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.66,156.62,
HEMOCLIP LG.,2102195,CDM,272,RC,,,outpatient,,,17.93,10.76,,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,16.14,
HEMOVAC 19F,2103277,CDM,272,RC,,,outpatient,,,217.8,130.68,,163.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,163.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,137.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.63,196.02,
HEMOVAC 400ML 1/8 2540-000-10,2101498,CDM,272,RC,,,outpatient,,,285.47,171.28,,214.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,214.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,214.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,179.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.49,256.92,
HEMOVAC 400ML 3/16,2100186,CDM,272,RC,,,outpatient,,,274.82,164.89,,206.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,206.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,206.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,173.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.31,247.34,
HEMOVAC BARD 0043630,2111494,CDM,272,RC,,,outpatient,,,176.85,106.11,,132.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,111.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.24,159.17,
HEMOVAC BARD 0043660,2111492,CDM,272,RC,,,outpatient,,,227.35,136.41,,170.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,170.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.58,204.62,
HEMOVAC BARD 0070720,2111493,CDM,272,RC,,,outpatient,,,210.06,126.04,,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,132.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.04,189.05,
HISTOACRYL CMP-BG-02,2111365,CDM,272,RC,,,outpatient,,,127.21,76.33,,95.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.07,114.49,
HMP CATH POLY ACUTE 4 EXT,2103111,CDM,272,RC,,,outpatient,,,860.17,516.1,,645.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,688.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,645.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,774.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,645.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,645.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,541.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.25,774.15,
HMP CATH SILICONE CIRCLE C,2108601,CDM,272,RC,,,outpatient,,,577.97,346.78,,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,364.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.43,520.17,
HMP LIFE PORT 7FR,2102980,CDM,272,RC,,,outpatient,,,1523.35,914.01,,1142.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1218.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,324.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1142.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1371.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1142.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1142.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,959.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312.13,1371.02,
HMP PORT VASCULAR ACCESS SYSTEM,2102979,CDM,272,RC,,,outpatient,,,1636.23,981.74,,1227.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1308.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1227.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1472.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1227.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1227.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1227.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1227.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1030.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.26,1472.61,
HMP SILICONE CATH CIRCLE C,2108719,CDM,272,RC,,,outpatient,,,385.32,231.19,,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,242.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.95,346.79,
HMP SILICONE CATH CIRCLE C,2108720,CDM,272,RC,,,outpatient,,,385.32,231.19,,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,242.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.95,346.79,
HOMER MAMMALOK NEEDLE 20GX12.5CM 231125G,2111306,CDM,272,RC,,,outpatient,,,58.77,35.26,,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.04,52.89,
HOSPIRA SAPPHIRE INFUSION SET,2109389,CDM,272,RC,,,outpatient,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,43.52,
I CATH 14GX2 NEEDLE 16X8 CATH,2100409,CDM,272,RC,,,outpatient,,,27.37,16.42,,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.61,24.63,
I CATH 16X8,2101973,CDM,272,RC,,,outpatient,,,43.07,25.84,,32.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.83,38.76,
I CATH 22X8 CATH 19G NEEDLE,2101972,CDM,272,RC,,,outpatient,,,44.45,26.67,,33.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.11,40.01,
IDENTI LOOPS WHITE,2102831,CDM,272,RC,,,outpatient,,,46.58,27.95,,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,41.92,
IDENTI VESA LOOP BLUE 011012PBX,2102830,CDM,272,RC,,,outpatient,,,46.58,27.95,,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,41.92,
IDENTI VESA LOOPS RED,2102829,CDM,272,RC,,,outpatient,,,50.82,30.49,,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,45.74,
IMED BLOOD SET 10015414,2102999,CDM,272,RC,,,outpatient,,,36.05,21.63,,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,32.45,
IMED BURETROL 2441-0007,2103165,CDM,272,RC,,,outpatient,,,99.44,59.66,,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.38,89.5,
IMED EXT 20019E,2109068,CDM,272,RC,,,outpatient,,,18.88,11.33,,14.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.87,16.99,
IMED EXT 30202E,2109038,CDM,272,RC,,,outpatient,,,18.78,11.27,,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.85,16.9,
IMED EXT 30262E,2100072,CDM,272,RC,,,outpatient,,,25.88,15.53,,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,23.29,
IMED EXT X-RAY 20018E,2111003,CDM,272,RC,,,outpatient,,,16.67,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,15,
IMED FILTER 20028E,2100155,CDM,272,RC,,,outpatient,,,139.05,83.43,,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.49,125.15,
IMED NITROSET 2260-0500,2102998,CDM,272,RC,,,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,92.44,
IMED PRIMARY 2426-0500,2112159,CDM,272,RC,,,outpatient,,,50.18,30.11,,37.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.28,45.16,
IMED PRIMARY 42493E,2102767,CDM,272,RC,,,outpatient,,,37.43,22.46,,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,33.69,
IMED PRIMARY SET,2103000,CDM,272,RC,,,outpatient,,,32.25,19.35,,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.61,29.03,
IMED PRIMARY SYR 2280-0000,2102997,CDM,272,RC,,,outpatient,,,60.15,36.09,,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,54.14,
IMED PRIMARY VENTED 42233E,2102701,CDM,272,RC,,,outpatient,,,34.27,20.56,,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,30.84,
IMED SECONDARY,2103175,CDM,272,RC,,,outpatient,,,19.52,11.71,,14.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,17.57,
IMED SECONDARY 72215N,2103293,CDM,272,RC,,,outpatient,,,23.02,13.81,,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.72,20.72,
INCISE 35,2108443,CDM,272,RC,,,outpatient,,,206.35,123.81,,154.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,130,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.28,185.72,
INNER DYNE 5MM CANNULA S101005,2108399,CDM,272,RC,,,outpatient,,,739.23,443.54,,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,157.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,465.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.47,665.31,
INSTRU MATE,2108413,CDM,272,RC,,,outpatient,,,136.59,81.95,,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,122.93,
INSUFFLATION TUBING,2102708,CDM,272,RC,,,outpatient,,,44.14,26.48,,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,39.73,
INSUFLOW 6198,2109251,CDM,272,RC,,,outpatient,,,723.39,434.03,,542.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,578.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,542.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,651.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,542.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,455.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.22,651.05,
INT STYLET 6 FR,2101273,CDM,272,RC,,,outpatient,,,27.04,16.22,,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,24.34,
INT STYLETTE 8FR,2102894,CDM,272,RC,,,outpatient,,,42.89,25.73,,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,38.6,
INTEGRA PIP DISP PACK,2112208,CDM,272,RC,,,outpatient,,,1054.96,632.98,,791.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,843.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,224.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,791.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,949.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,791.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,791.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,791.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,791.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,664.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.16,949.46,
INTRAOSSCOS NEEDLE 15G DIN1515X,2111982,CDM,272,RC,,,outpatient,,,56.28,33.77,,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,50.65,
INTRAOSSCOSS NEEDLE 18G DIN1518X,2111983,CDM,272,RC,,,outpatient,,,56.28,33.77,,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,50.65,
IOBAN 2 405682*,2108998,CDM,272,RC,,,outpatient,,,56.65,33.99,,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,50.99,
IOBAN 2 6640EZ,2109338,CDM,272,RC,,,outpatient,,,37.97,22.78,,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.78,34.17,
IOBAN 2 6640EZ,2111214,CDM,272,RC,,,outpatient,,,29.18,17.51,,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,26.26,
J & J BIOPATCH 1 W/7CM HOLE,2103087,CDM,272,RC,,,outpatient,,,49.97,29.98,,37.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,44.97,
J & J DYNA FLEX COMPRESSION SYSTEM,2108458,CDM,272,RC,,,outpatient,,,181.2,108.72,,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,163.08,
J & J FIBRACOL 3/8 X 3/8 X 15 3/4,2103080,CDM,272,RC,,,outpatient,,,87.84,52.7,,65.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18,79.06,
J & J FIBRACOL PLUS 4 X4 3 X8,2103079,CDM,272,RC,,,outpatient,,,75.22,45.13,,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,67.7,
J & J INTERCEED TC7 4350,2108826,CDM,272,RC,,,outpatient,,,617.67,370.6,,463.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,463.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,463.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,389.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.56,555.9,
J & J NUGEL 6 X 8,2103083,CDM,272,RC,,,outpatient,,,77.98,46.79,,58.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.98,70.18,
J & J TIELLE 18X18 MTL 104,2103236,CDM,272,RC,,,outpatient,,,99.91,59.95,,74.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.47,89.92,
J & J TIELLE MTL 101,2103237,CDM,272,RC,,,outpatient,,,19.57,11.74,,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,17.61,
J & J TIELLE MTL100*,2108459,CDM,272,RC,,,outpatient,,,11.33,6.8,,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,10.2,
J & J TYMPANTIC PATTIES 1/2X1/2,2103378,CDM,272,RC,,,outpatient,,,6.15,3.69,,4.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,5.54,
J VAC 2162 RESEVOIR,2101247,CDM,272,RC,,,outpatient,,,244.75,146.85,,183.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,183.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,154.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.15,220.28,
J VAC 2189 DRAIN,2101246,CDM,272,RC,,,outpatient,,,298.43,179.06,,223.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,223.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,188.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.15,268.59,
JACKSON PRATT 10MM DRAIN/W TROCAR -1411,2102887,CDM,272,RC,,,outpatient,,,513.04,307.82,,384.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,384.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,384.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,323.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.12,461.74,
JACKSON PRATT 7MM X 20CM,2103271,CDM,272,RC,,,outpatient,,,388.73,233.24,,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,244.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,349.86,
JACKSON PRATT HYSTERECTOMY DRAIN PT 2,2103265,CDM,272,RC,,,outpatient,,,204.89,122.93,,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.98,184.4,
JACKSON PRATT HYSTERECTOMY T TUBE R 19F,2102611,CDM,272,RC,,,outpatient,,,400.22,240.13,,300.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,300.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,300.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,252.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.01,360.2,
JAMSHIDI NEEDLE,2100406,CDM,272,RC,,,outpatient,,,94.2,56.52,,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.3,84.78,
JELCO 14G X 1X1/4,2102803,CDM,272,RC,,,outpatient,,,37.15,22.29,,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,33.44,
JELCO 18G X1 3/4 5858004424,2111142,CDM,272,RC,,,outpatient,,,8.61,5.17,,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,7.75,
JELCO 18GA 2302004425,2100063,CDM,272,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
JELCO 18GA PROTECTIVE PLUS,2108415,CDM,272,RC,,,outpatient,,,12.36,7.42,,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,11.12,
JELCO 20GA,2100062,CDM,272,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
JELCO 20GA PROTECTIVE PLUS,2108416,CDM,272,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
JELCO 20GX1 3/4,2113202,CDM,272,RC,,,outpatient,,,8.61,5.17,,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,7.75,
JELCO 22G PROTECTIVE PLUS,2108417,CDM,272,RC,,,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,6.49,
JELCO 24G PROTECTIVE PLUS,2108428,CDM,272,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
JELCO PROTECTIVE 16G,2103808,CDM,272,RC,,,outpatient,,,16.97,10.18,,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,15.27,
JELCO PROTECTIVE 18G,2103809,CDM,272,RC,,,outpatient,,,24.32,14.59,,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,21.89,
JELCO PROTECTIVE 20G,2103810,CDM,272,RC,,,outpatient,,,24.32,14.59,,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,21.89,
JELCO PROTECTIVE 22G,2103812,CDM,272,RC,,,outpatient,,,24.32,14.59,,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,21.89,
JELCO PROTECTIVE 24G,2103811,CDM,272,RC,,,outpatient,,,17.93,10.76,,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,16.14,
K C IMP STOCK MED 89811,2109736,CDM,272,RC,,,outpatient,,,28.12,16.87,,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,25.31,
K DISSECTOR (P W TELEFLEX),2103202,CDM,272,RC,,,outpatient,,,15.3,9.18,,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,13.77,
K DISSECTOR ROSEBUD,2100182,CDM,272,RC,,,outpatient,,,34.69,20.81,,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,31.22,
KANGAROO PUMP TUBING 1000 ML 773656,2112669,CDM,272,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
KENDALL J WIRE 8813796-001,2102686,CDM,272,RC,C1769,HCPCS,outpatient,,,125.94,75.56,,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.81,113.35,
KERLIX 4X4,2102876,CDM,272,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
KERLIX KLING 4 1/2,2102658,CDM,272,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
KIT CMG,2109080,CDM,272,RC,,,outpatient,,,81.79,49.07,,61.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.76,73.61,
KIT FALLOPIAN,2108973,CDM,272,RC,,,outpatient,,,244.85,146.91,,183.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,183.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,154.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.17,220.37,
KIT GASTRIC LAVAGL,2102809,CDM,272,RC,,,outpatient,,,240.95,144.57,,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,216.86,
KIT PED TRAUMA E,2108760,CDM,272,RC,,,outpatient,,,343.09,205.85,,257.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,257.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,216.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.3,308.78,
KIT VASCULAR TOURNIQUET,2102967,CDM,272,RC,,,outpatient,,,81.41,48.85,,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,73.27,
KLING 1 IN,2102408,CDM,272,RC,,,outpatient,,,4.03,2.42,,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.83,3.63,
KLING 2 IN,2100240,CDM,272,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
KLING 3 IN,2100241,CDM,272,RC,,,outpatient,,,5.15,3.09,,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.64,
KLING 4 IN,2100242,CDM,272,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
KLING 6 IN,2100243,CDM,272,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
KMS EASY-TRACH ADULT KIT,2108735,CDM,272,RC,,,outpatient,,,310.21,186.13,,232.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.56,279.19,
KOL BIO MEDICAL PRESSURE CATHETER,2108610,CDM,272,RC,,,outpatient,,,564.94,338.96,,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,355.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,508.45,
KOL KIWI COMP VAC DEL SYS VAC6000M,2102627,CDM,272,RC,,,outpatient,,,310.34,186.2,,232.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.59,279.31,
KUMAR CATH KC002,2109093,CDM,272,RC,,,outpatient,,,257.06,154.24,,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,161.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,231.35,
LANCET TENDER FOOT TF200A,2109107,CDM,272,RC,,,outpatient,,,17.21,10.33,,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,15.49,
LEG BAG,2100196,CDM,272,RC,,,outpatient,,,9.97,5.98,,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,8.97,
LEG BAG TELEFLEX*,2111951,CDM,272,RC,,,outpatient,,,19.94,11.96,,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,17.95,
LEG STRAP FABRIC 150507,2111922,CDM,272,RC,,,outpatient,,,9.84,5.9,,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,8.86,
LINVATEC TROCAR 8.4X90MM C7372,2109755,CDM,272,RC,,,outpatient,,,192.76,115.66,,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.5,173.48,
LINVATEC TROCAR C7362,2109742,CDM,272,RC,,,outpatient,,,192.76,115.66,,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.5,173.48,
LMA 3 TRI ANIM 329-038-94-330UE,2112510,CDM,272,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
LMA 4 TRI ANIM 329-038-94-340UE,2112511,CDM,272,RC,,,outpatient,,,20.6,12.36,,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.54,
LMA 5 TRI ANIM 329-038-94-350UE,2112512,CDM,272,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,36.14,
LMA AIR Q 1.5 10-3015,2112328,CDM,272,RC,,,outpatient,,,88.58,53.15,,66.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.15,79.72,
LMA AIR Q 2.5 103025,2109292,CDM,272,RC,,,outpatient,,,283.01,169.81,,212.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,178.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,254.71,
LMA AIR Q 3.5 10-3035,2111780,CDM,272,RC,,,outpatient,,,12.36,7.42,,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,11.12,
LMA AIR Q 4.5 10-3045,2111781,CDM,272,RC,,,outpatient,,,12.36,7.42,,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,11.12,
LOPEZ ENTERNAL VALVE,2100633,CDM,272,RC,,,outpatient,,,4.12,2.47,,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,3.71,
LUKI TUBES*,2100194,CDM,272,RC,,,outpatient,,,12.36,7.42,,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,11.12,
MAD NASAL DEVICE,2113252,CDM,272,RC,,,outpatient,,,112.53,67.52,,84.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,101.28,
MASTISOL 2/3CC VIAL,2103026,CDM,272,RC,,,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
MAYO STAND COVER LG,2103099,CDM,272,RC,,,outpatient,,,13.05,7.83,,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,11.75,
MED COMP CATH SET JDDF1528,2109364,CDM,272,RC,C1750,HCPCS,outpatient,,,1076.92,646.15,,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,861.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,969.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,678.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,969.23,
MED COMP FLOW CATH SET 32CM JDDF1532,2109365,CDM,272,RC,C1750,HCPCS,outpatient,,,1076.92,646.15,,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,861.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,969.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,678.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,969.23,
MED COMP FLOW CATH SET JDDF1524,2109366,CDM,272,RC,C1750,HCPCS,outpatient,,,1076.92,646.15,,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,861.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,969.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,807.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,678.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.66,969.23,
MEDCOMP 14FX55 SPLIT CATH II SET ASPC55-,2109445,CDM,272,RC,,,outpatient,,,991.3,594.78,,743.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,793.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,743.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,892.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,743.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,624.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.12,892.17,
MEDCOMP 16F INTRODUCER MCVSI 16,2109442,CDM,272,RC,,,outpatient,,,197.97,118.78,,148.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,124.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.56,178.17,
MEDCOMP ASH SPLIT,2109447,CDM,272,RC,,,outpatient,,,954.17,572.5,,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,858.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,601.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,858.75,
MEDCOMP ASH SPLIT CATH 14X28 T552-2,2109448,CDM,272,RC,,,outpatient,,,954.17,572.5,,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,858.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,601.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,858.75,
MEDCOMP ASH SPLIT CATH 14X40 T634-2,2109446,CDM,272,RC,,,outpatient,,,954.17,572.5,,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,858.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,601.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,858.75,
MEDCOMP ASH SPLIT CATH II 14X24 T593-2,2109449,CDM,272,RC,,,outpatient,,,954.17,572.5,,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,858.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,715.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,601.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.51,858.75,
MEDCOMP REPAIR KIT RPK-01,2109441,CDM,272,RC,,,outpatient,,,588.48,353.09,,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,370.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.58,529.63,
MEDCOMP SOFT LINE IJ CATH KIT DFXL146IJ,2109443,CDM,272,RC,,,outpatient,,,391.58,234.95,,293.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,293.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,293.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.23,352.42,
MEDCOMP TESIO 10F LEFT BFL-6,2109439,CDM,272,RC,,,outpatient,,,782.94,469.76,,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,626.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,493.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.42,704.65,
MEDCOMP TESIO 10F RIGHT BFR-6,2109440,CDM,272,RC,,,outpatient,,,782.94,469.76,,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,626.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,493.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.42,704.65,
MEDCOMP TESIO VENOUS EXT SET MC11V,2109444,CDM,272,RC,,,outpatient,,,103.01,61.81,,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,92.71,
MEDELA BREAST PUMP DOUBLE 67340S,2109003,CDM,272,RC,,,outpatient,,,254.88,152.93,,191.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,160.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.22,229.39,
MEDELA CONTACT NIPPLE 16MM 67251,2111941,CDM,272,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
MEDELA CONTACT NIPPLE 20MM 67218,2111942,CDM,272,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
MEDELA CONTACT NIPPLE 24MM 67203,2111943,CDM,272,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
MEDIGROUP CATH EXTENDER REP KIT CE1350,2109486,CDM,272,RC,,,outpatient,,,478.15,286.89,,358.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,358.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,430.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,358.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,301.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.97,430.34,
MEDIIV AUXILLIARY WATER PORT CONNECTOR,2112850,CDM,272,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
MEDIIV ENDOGATOR KIT 100601,2112535,CDM,272,RC,,,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,143.83,
MEDIIV ENDOGATOR KIT 100603,2112849,CDM,272,RC,,,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,143.83,
MEDIVATORS Y-OPSY IRRIGATOR 100303,2112543,CDM,272,RC,,,outpatient,,,127.72,76.63,,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,114.95,
MEDLINE ARTHR PLUS PACK DYNJP8120,2109957,CDM,272,RC,,,outpatient,,,128.12,76.87,,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.25,115.31,
MEDLINE BILATERAL EXTREMITY SHEET,2109157,CDM,272,RC,,,outpatient,,,83.33,50,,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,75,
MEDLINE BLADE CLIPPER ASSEMBLY DYND70880,2103219,CDM,272,RC,,,outpatient,,,14.42,8.65,,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,12.98,
MEDLINE BLADE CLIPPER SHAVER DYND70851,2112066,CDM,272,RC,,,outpatient,,,47.53,28.52,,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,42.78,
MEDLINE DRAPE DYNJP8330,2109903,CDM,272,RC,,,outpatient,,,84.23,50.54,,63.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.26,75.81,
MEDLINE HIP PACK V DYNJP8240,2109958,CDM,272,RC,,,outpatient,,,78.14,46.88,,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.01,70.33,
MEDLINE KNEE ARTHROSCOPY KIT,2109777,CDM,272,RC,,,outpatient,,,424.79,254.87,,318.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,318.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,318.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,267.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.04,382.31,
MEDLINE SHOULDER PACK DYNJS0841,2109776,CDM,272,RC,,,outpatient,,,450.2,270.12,,337.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,360.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,337.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,337.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,283.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.25,405.18,
MEDLINE SHOULDER POUCH DYNJSD1067,2110814,CDM,272,RC,,,outpatient,,,121.01,72.61,,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.79,108.91,
MEDLINE SHOULDER SUSPENSION KIT,2109775,CDM,272,RC,,,outpatient,,,72.4,43.44,,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,65.16,
MEDLINE STAPLE REMOVER KIT,2112573,CDM,272,RC,,,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,49.42,
MEDLINE TABLE COVER 50X90 DYNJP2316,2110759,CDM,272,RC,,,outpatient,,,13.67,8.2,,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,12.3,
MEGA DYNE ELECTRODE 0440,2109137,CDM,272,RC,,,outpatient,,,98.34,59,,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,88.51,
MEGA DYNE LOOP ELECTRODE 0480,2109074,CDM,272,RC,,,outpatient,,,87.14,52.28,,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.85,78.43,
MEGA L HOOK,2102897,CDM,272,RC,,,outpatient,,,710.28,426.17,,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,639.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,447.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.54,639.25,
MEGADYNE BALL ELECTRODE,2103797,CDM,272,RC,,,outpatient,,,125.12,75.07,,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.64,112.61,
MEGADYNE E-Z CLEAN BALL TIP ELECTRODE,2102113,CDM,272,RC,,,outpatient,,,96.71,58.03,,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.82,87.04,
MEGADYNE E-Z CLEAN CAU TIP 012,2101990,CDM,272,RC,,,outpatient,,,146.42,87.85,,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,131.78,
MEGADYNE E-Z CLEAN EXT BL ELEC 014,2101991,CDM,272,RC,,,outpatient,,,189.59,113.75,,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,119.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.85,170.63,
MEGADYNE LAP RET ELEC SPACULA,2102966,CDM,272,RC,,,outpatient,,,689.59,413.75,,517.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,551.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,146.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,517.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,620.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,517.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,434.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.3,620.63,
MEGADYNE LOOP ELECTRODE,2103071,CDM,272,RC,,,outpatient,,,136.87,82.12,,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,123.18,
MEGADYNE MED BLADE,2103149,CDM,272,RC,,,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,72.04,
MEPITEL 2X3 290510,2108902,CDM,272,RC,,,outpatient,,,40.74,24.44,,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.35,36.67,
MEPITEL 3X4 290710,2108903,CDM,272,RC,,,outpatient,,,72.78,43.67,,54.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.91,65.5,
MEPITEL 9X12 292005,2108905,CDM,272,RC,A6208,HCPCS,outpatient,,,374.28,224.57,,280.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.69,336.85,
MERIT ANGIO KIT K12T-02680,2110571,CDM,272,RC,,,outpatient,,,314.45,188.67,,235.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,198.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.43,283.01,
MINI DRIVER SAGITTAL BLADE FINE K155,2109766,CDM,272,RC,,,outpatient,,,123.81,74.29,,92.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.37,111.43,
MIXING BOWL 210098,2109905,CDM,272,RC,,,outpatient,,,174.63,104.78,,130.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,110.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.78,157.17,
MIXING SYSTEM 712700,2109894,CDM,272,RC,,,outpatient,,,287.5,172.5,,215.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.91,258.75,
MORGAN MEDI-FLOW LENS MT2000,2112832,CDM,272,RC,,,outpatient,,,106.28,63.77,,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.78,95.65,
MST MALYUGIN RING SYSTEM,2112490,CDM,272,RC,,,outpatient,,,307.61,184.57,,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,193.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.03,276.85,
MST MALYUGIN RING SYSTEM 2.0 6.25 UPGR,2112787,CDM,272,RC,,,outpatient,,,307.61,184.57,,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,193.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.03,276.85,
MULTI TRAUMA DRESS 8901377,2100027,CDM,272,RC,,,outpatient,,,33.33,20,,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,30,
NANO IV CATH 26GX.056,2102988,CDM,272,RC,,,outpatient,,,20.95,12.57,,15.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,18.86,
NASAL CATH SILICONE EPISTAT,2102638,CDM,272,RC,,,outpatient,,,424.58,254.75,,318.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,318.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,318.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,267.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87,382.12,
NASAL SPLINT LG BROWN,2103354,CDM,272,RC,,,outpatient,,,16.97,10.18,,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,15.27,
NASAL SPLINT MED BROWN,2103353,CDM,272,RC,,,outpatient,,,16.97,10.18,,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,15.27,
NASAL SPLINT SM BROWN,2103355,CDM,272,RC,,,outpatient,,,16.97,10.18,,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.48,15.27,
NASAL TAMPON,2102637,CDM,272,RC,,,outpatient,,,116.38,69.83,,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,104.74,
NASOPHARYNGEAL AIR 24F 6.0,2102895,CDM,272,RC,,,outpatient,,,63.1,37.86,,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,56.79,
NASOPHARYNGEAL AIR 26F 6.5,2109184,CDM,272,RC,,,outpatient,,,13.11,7.87,,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.69,11.8,
NASOPHARYNGEAL AIR 32F 8.0*,2101527,CDM,272,RC,,,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,49.42,
NASOPHARYNGEAL AIR 50MM 14F 125200,2109550,CDM,272,RC,,,outpatient,,,91.02,54.61,,68.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.65,81.92,
NEB W/ADAPTER 500ML 3D0807,2109118,CDM,272,RC,,,outpatient,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,28.28,
NEEDLE COUNTER KLEEN TEST PN31142295,2102388,CDM,272,RC,,,outpatient,,,39.89,23.93,,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,35.9,
NEEDLE EPIDURAL TUOHY 17GX4 1/2,2109226,CDM,272,RC,,,outpatient,,,63.1,37.86,,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.93,56.79,
NEEDLE ROUND BODY SIZE 6,2109247,CDM,272,RC,,,outpatient,,,14.33,8.6,,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,12.9,
NEEDLE ROUND BODY SIZE 8,2109248,CDM,272,RC,,,outpatient,,,14.33,8.6,,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,12.9,
NEEDLE SPINAL AX BLOCK 22X1 9440,2109608,CDM,272,RC,,,outpatient,,,13.05,7.83,,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.67,11.75,
NEEDLE SPINAL PENCAN 25X6 333877,2109229,CDM,272,RC,,,outpatient,,,59.55,35.73,,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,53.6,
NEEDLE SPINAL PENCON 27G X 5,2112067,CDM,272,RC,,,outpatient,,,51.91,31.15,,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,46.72,
NEEDLE SPINAL PENCON 27X5 3584333876,2109228,CDM,272,RC,,,outpatient,,,51.91,31.15,,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,46.72,
NEEDLE TRUCUT DISP.,2102486,CDM,272,RC,,,outpatient,,,162.54,97.52,,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.3,146.29,
NITROGLYCERINE SET,2100599,CDM,272,RC,,,outpatient,,,169.11,101.47,,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,106.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.65,152.2,
NORMAL SALINE 1000CC BAG 2B1324X,2112844,CDM,272,RC,,,outpatient,,,15.57,9.34,,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,14.01,
NORMAL SALINE 1000ML,2102293,CDM,272,RC,,,outpatient,,,11.74,7.04,,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,10.57,
NORMAL SALINE 1500ML,2111944,CDM,272,RC,,,outpatient,,,12.3,7.38,,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,11.07,
NORMAL SALINE 250ML,2112311,CDM,272,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
NORMAL SALINE 500ML,2100141,CDM,272,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
NOVA SURE KIT,2110947,CDM,272,RC,C2618,HCPCS,outpatient,,,2136.55,1281.93,,1602.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1709.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,455.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,455.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1602.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,459.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1922.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1602.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1602.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1602.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1602.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1346.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.78,1922.9,
NOVA SURE KIT NS2007,2111280,CDM,272,RC,,,outpatient,,,2955.29,1773.17,,2216.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2364.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,629.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2216.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,635.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2659.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2216.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2216.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,605.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1861.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,605.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,605.54,2659.76,
NUGAUZE 1 IODO,2101322,CDM,272,RC,,,outpatient,,,69.11,41.47,,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.16,62.2,
NUGAUZE 1 PLAIN,2100021,CDM,272,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
NUGAUZE 1/2 IODO*,2100020,CDM,272,RC,,,outpatient,,,34.97,20.98,,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,31.47,
NUGAUZE 1/2 PLAIN,2100019,CDM,272,RC,,,outpatient,,,47.27,28.36,,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,42.54,
NUGAUZE 1/4 IODO*,2100022,CDM,272,RC,,,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,39.58,
NUGAUZE 1/4 PLAIN,2101382,CDM,272,RC,,,outpatient,,,49.45,29.67,,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.13,44.51,
NUGAUZE 2 IODO*,2101252,CDM,272,RC,,,outpatient,,,76.77,46.06,,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,69.09,
NUGAUZE 2 PLAIN,2101383,CDM,272,RC,,,outpatient,,,78.95,47.37,,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.18,71.06,
OBAGI SKIN PREP,2109143,CDM,272,RC,,,outpatient,,,588.48,353.09,,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,370.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.58,529.63,
OPSITE 2 1/2 X 2,2103074,CDM,272,RC,,,outpatient,,,2.66,1.6,,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,2.39,
OPSITE 4X5 1/2,2108568,CDM,272,RC,,,outpatient,,,1.03,0.62,,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,0.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.21,0.93,
OPSITE 5 1/2X10,2103790,CDM,272,RC,,,outpatient,,,55.81,33.49,,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,50.23,
OPSITE DRESSING 5 1/2 x 4,2100510,CDM,272,RC,,,outpatient,,,13.37,8.02,,10.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,12.03,
OPSITE DRESSING 8X6 MED,2101962,CDM,272,RC,,,outpatient,,,19.84,11.9,,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,17.86,
OPSITE DRESSING LG 11 3/4X11,2100511,CDM,272,RC,,,outpatient,,,39.68,23.81,,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,35.71,
OSTOMY CENTER POINT LOCK KIT,2108572,CDM,272,RC,,,outpatient,,,222.1,133.26,,166.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.51,199.89,
OSTOMY CONVATEC WAFER 1 3/4 413161,2103449,CDM,272,RC,A4424,HCPCS,outpatient,,,29.5,17.7,,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,26.55,
OSTOMY CONVATEC WAFER 2 1/4 413162,2112348,CDM,272,RC,,,outpatient,,,23.69,14.21,,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.85,21.32,
OSTOMY CONVATEC WAFER 2 3/4,2113028,CDM,272,RC,,,outpatient,,,134.96,80.98,,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.65,121.46,
OSTOMY HOLLISTER 2' POUCH,2102371,CDM,272,RC,A4418,HCPCS,outpatient,,,19.94,11.96,,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.09,17.95,
OSTOMY HOLLISTER BAG,2108570,CDM,272,RC,,,outpatient,,,25.95,15.57,,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,23.36,
OSTOMY POUCH DRAINABLE 1 3/4,2109693,CDM,272,RC,A4424,HCPCS,outpatient,,,19.67,11.8,,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.03,17.7,
OSTOMY POUCH DRAINABLE 2 1/4 401935,2112349,CDM,272,RC,,,outpatient,,,10.3,6.18,,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.11,9.27,
OSTOMY POUCH DRAINABLE 401514,2113029,CDM,272,RC,A4424,HCPCS,outpatient,,,171.02,102.61,,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,107.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.04,153.92,
OSTOMY STOMA PASTE 183910,2109691,CDM,272,RC,A4405,HCPCS,outpatient,,,63.93,38.36,,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,57.54,
OSTOMY STOMA POWDER 172,2109692,CDM,272,RC,A4373,HCPCS,outpatient,,,54.1,32.46,,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,48.69,
OSTOMY TAIL CLOSURE,2101704,CDM,272,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
OSTOMY WIPES 174,2112350,CDM,272,RC,A4373,HCPCS,outpatient,,,68.85,41.31,,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.11,61.97,
OXISENSOR II ADULT NASAL 02 R15,2109131,CDM,272,RC,,,outpatient,,,128.67,77.2,,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,115.8,
PAC KIT-5,2100584,CDM,272,RC,,,outpatient,,,237.54,142.52,,178.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,149.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.67,213.79,
PACEMAKER CABLE DISP,2102060,CDM,272,RC,,,outpatient,,,177.81,106.69,,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,112.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.43,160.03,
PACEMAKER INTRODUCER 6209-S5S,2102422,CDM,272,RC,,,outpatient,,,488.12,292.87,,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,439.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,307.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.02,439.31,
PACEMAKER INTRODUCER 9 FR S23218,2111226,CDM,272,RC,,,outpatient,,,488.12,292.87,,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,439.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,307.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.02,439.31,
PACEMAKER INTRODUCER 9F SOLOTRACK,2102808,CDM,272,RC,,,outpatient,,,415.03,249.02,,311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,261.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.04,373.53,
PACEMAKER LEAD CAPSURE FIX NOVUS 5076,2100477,CDM,272,RC,,,outpatient,,,1655,993,,1241.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1324,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,352.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1241.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1489.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1241.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1042.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.11,1489.5,
PACEMAKER ROTATION TOOL KIT,2110605,CDM,272,RC,,,outpatient,,,183.96,110.38,,137.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,115.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.69,165.56,
PACEMAKER SERVICE KIT,2108584,CDM,272,RC,,,outpatient,,,465.21,279.13,,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,418.69,
PACEMAKER STERILE SLEEVE 6177,2111100,CDM,272,RC,,,outpatient,,,100.36,60.22,,75.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,63.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.56,90.32,
PACEMAKER STYLET KIT,2108583,CDM,272,RC,,,outpatient,,,516.98,310.19,,387.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,387.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,387.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,325.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.93,465.28,
PACEMAKER TRANSMITTER,2102059,CDM,272,RC,,,outpatient,,,680.68,408.41,,510.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,510.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,612.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,510.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,428.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.47,612.61,
PACEMAKER WRENCH KIT,2108582,CDM,272,RC,,,outpatient,,,465.21,279.13,,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.32,418.69,
PACK ARTHROSCOPY,2109741,CDM,272,RC,,,outpatient,,,227.25,136.35,,170.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,170.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.56,204.53,
PACK ARTHROSCOPY KNEE,2109733,CDM,272,RC,,,outpatient,,,345.33,207.2,,259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,217.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.76,310.8,
PACK BEACH CHAIR SHOULDER,2109734,CDM,272,RC,,,outpatient,,,406.77,244.06,,305.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,305.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,366.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,305.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,256.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.35,366.09,
PACK C-SECTION,2101410,CDM,272,RC,,,outpatient,,,437.37,262.42,,328.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,328.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,393.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,275.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.62,393.63,
PACK ENDO LAP COMBO A009.19,2108953,CDM,272,RC,,,outpatient,,,248.87,149.32,,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.99,223.98,
PACK ENT,2103303,CDM,272,RC,,,outpatient,,,217.45,130.47,,163.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,163.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,136.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.56,195.71,
PACK LAP CHOLE CDS CDS930152A,2109610,CDM,272,RC,,,outpatient,,,1559.95,935.97,,1169.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1247.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,332.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1169.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1403.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1169.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1169.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1169.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1169.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,982.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.63,1403.96,
PACK ORTHO MAJOR*,2109732,CDM,272,RC,,,outpatient,,,174.07,104.44,,130.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.67,156.66,
PACK PRESOURCE DYNJ24930,2109457,CDM,272,RC,,,outpatient,,,293.87,176.32,,220.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,220.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,185.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.21,264.48,
PALL BLOOD TRANSFUSION FILTER,2109968,CDM,272,RC,,,outpatient,,,55.17,33.1,,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,49.65,
PAP SMEAR KIT,2100173,CDM,272,RC,,,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,49.42,
PCA ADMINISTRATION KIT,2112651,CDM,272,RC,,,outpatient,,,52.18,31.31,,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,46.96,
PENROSE DRAIN 1/4X18 DYNACOR,2101631,CDM,272,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,6.4,
PENROSE DRAIN 1X5/8X18 ARGYLE,2101630,CDM,272,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
PENROSE DRAIN MEDLINE,2108627,CDM,272,RC,,,outpatient,,,5.19,3.11,,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.67,
PERCUTANEOUS NEEDLE,2100592,CDM,272,RC,,,outpatient,,,21.75,13.05,,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,19.58,
PERM CATH 45CM,2108960,CDM,272,RC,,,outpatient,,,465.84,279.5,,349.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,349.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,349.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.45,419.26,
PERM CATH INTRODUCER NEEDLE 7CM,2102527,CDM,272,RC,,,outpatient,,,25.88,15.53,,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.3,23.29,
PERM-CATH TESIO,2103075,CDM,272,RC,,,outpatient,,,993,595.8,,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,625.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.47,893.7,
PERM-CATH TESIO RED CAPS,2103102,CDM,272,RC,,,outpatient,,,163.06,97.84,,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,146.75,
PESSARY VAG SIZE 3,2112030,CDM,272,RC,,,outpatient,,,171.34,102.8,,128.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,107.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.11,154.21,
PICC INTRODUCER 20G3FR 384010,2103436,CDM,272,RC,,,outpatient,,,305.96,183.58,,229.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,192.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.69,275.36,
PICC L CATH DUAL 20G 3 FR X60CM 384466,2111232,CDM,272,RC,,,outpatient,,,150.75,90.45,,113.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.89,135.68,
PILLOW ABDUCTION 6034M60076M,2111537,CDM,272,RC,,,outpatient,,,266.08,159.65,,199.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,199.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,167.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.52,239.47,
PILLOW SNIFF ANES,2108393,CDM,272,RC,,,outpatient,,,145.02,87.01,,108.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,91.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.71,130.52,
PIPELLE ENDOMETRIAL SUCT CURETTE,2102711,CDM,272,RC,,,outpatient,,,76.22,45.73,,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,68.6,
PLEU EVAC INFANT,2102493,CDM,272,RC,,,outpatient,,,755.9,453.54,,566.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,604.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,161.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,566.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,680.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,566.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,476.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.88,680.31,
PLURAL EVAC ADULT/PED.,2102421,CDM,272,RC,,,outpatient,,,544.73,326.84,,408.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,408.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,408.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,343.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.62,490.26,
POOLE CONNECTORS 12' DYND50252,2100088,CDM,272,RC,,,outpatient,,,62.28,37.37,,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.76,56.05,
POOLE SUCTION,2100504,CDM,272,RC,,,outpatient,,,165.5,99.3,,124.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,104.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.91,148.95,
PORT A CATH 19 3/ 4G POWLOC KIT2131975,2112108,CDM,272,RC,,,outpatient,,,32.96,19.78,,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.75,29.66,
PORT A CATH 19 GX1 POWER LOC KIT2131910,2112107,CDM,272,RC,,,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,57.78,
PORT A CATH GRIPPER 22,2103358,CDM,272,RC,,,outpatient,,,60.15,36.09,,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,54.14,
PORT A CATH NEEDLE ONLY 19X1 1/2,2103112,CDM,272,RC,,,outpatient,,,39.68,23.81,,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.13,35.71,
POWERGLIDE DRES CHANGE TRAY M000001,2112267,CDM,272,RC,,,outpatient,,,27.37,16.42,,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.61,24.63,
PRECIP PACK,2101198,CDM,272,RC,,,outpatient,,,47.32,28.39,,35.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.7,42.59,
PRO TACKER 174006,2103261,CDM,272,RC,,,outpatient,,,2172.34,1303.4,,1629.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1737.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,462.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,462.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1629.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1955.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1629.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1629.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1368.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.11,1955.11,
PULSTAR OVERSIZE,2108426,CDM,272,RC,,,outpatient,,,405.05,243.03,,303.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,364.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,303.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,255.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.99,364.55,
PULSTAR S-XLG,2108427,CDM,272,RC,,,outpatient,,,378.53,227.12,,283.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,283.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,283.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,238.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.56,340.68,
QUICK COMBO ADULT 31121731,2112051,CDM,272,RC,,,outpatient,,,97.81,58.69,,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,88.03,
QUICK COMBO PED 31121730,2112050,CDM,272,RC,,,outpatient,,,97.81,58.69,,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,88.03,
QUICKTRACH ADULT 4MM 30100041,2101447,CDM,272,RC,,,outpatient,,,428.08,256.85,,321.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,321.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,385.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,321.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,269.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.71,385.27,
QUICKTRACH CHILD 2MM 120900020,2102192,CDM,272,RC,,,outpatient,,,265.26,159.16,,198.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,167.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.35,238.73,
RANGER FLOW DISP SET*,2112113,CDM,272,RC,,,outpatient,,,48.08,28.85,,36.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.85,43.27,
RAPID RHINO NASAL PACKING RR550,2111742,CDM,272,RC,,,outpatient,,,166.91,100.15,,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,150.22,
RAYTEC 4X4 ST.,2100387,CDM,272,RC,,,outpatient,,,86.88,52.13,,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.8,78.19,
ROSS 10F PEG KIT 51442,2111350,CDM,272,RC,,,outpatient,,,367.92,220.75,,275.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,275.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.39,331.13,
ROSS 18F GAS. TUBE PERC. ENDO COMP. KIT,2102443,CDM,272,RC,,,outpatient,,,486.11,291.67,,364.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,364.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,364.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,306.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.6,437.5,
ROSS 18F PEG KIT,2103805,CDM,272,RC,,,outpatient,,,491.3,294.78,,368.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,368.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.67,442.17,
ROSS GAS TUBE 18F,2103442,CDM,272,RC,,,outpatient,,,421.18,252.71,,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.3,379.06,
ROSS GASTROSTOMY Y PORT CONNECTOR,2103126,CDM,272,RC,,,outpatient,,,67.58,40.55,,50.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.85,60.82,
ROSS PEG KIT,2108952,CDM,272,RC,,,outpatient,,,324.95,194.97,,243.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,243.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,243.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.58,292.46,
ROTH RETRIEVAL BASKET,2108703,CDM,272,RC,,,outpatient,,,513.58,308.15,,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,462.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,323.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.23,462.22,
RT ETOC2 SENSOR RESPIRONICS 6063,2110703,CDM,272,RC,,,outpatient,,,120.75,72.45,,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,108.68,
RT INFANT VENT CIRCUITS 3280078010,2109705,CDM,272,RC,,,outpatient,,,25.95,15.57,,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,23.36,
RT NEO HME,2109779,CDM,272,RC,,,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
RT PEDI CAP CO2 DETECTOR 4130,2109778,CDM,272,RC,,,outpatient,,,82.5,49.5,,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,74.25,
RT PORTABLE VENT CIRCUITS L599-090,2109706,CDM,272,RC,,,outpatient,,,103.54,62.12,,77.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.22,93.19,
RT STERILE WATER 1000CC,2113190,CDM,272,RC,,,outpatient,,,15.57,9.34,,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,14.01,
RT TENT BRT-4110,2109300,CDM,272,RC,,,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,57.78,
RT UNI-HEART NEB 963-100940EA,2109707,CDM,272,RC,,,outpatient,,,31.93,19.16,,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,28.74,
S&N 3.2 GUIDE WIRE 71631690,2109867,CDM,272,RC,,,outpatient,,,180.78,108.47,,135.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.04,162.7,
S&N 71687002,2110383,CDM,272,RC,,,outpatient,,,218.44,131.06,,163.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,163.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,137.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.76,196.6,
S&N DRILL BIT,2112897,CDM,272,RC,,,outpatient,,,521.51,312.91,,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,469.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.86,469.36,
S&N DRILL BIT 7117,2110540,CDM,272,RC,,,outpatient,,,160.62,96.37,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,144.56,
S&N GRAD BALL TIP 71751146,2110470,CDM,272,RC,,,outpatient,,,348.72,209.23,,261.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,261.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,261.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,219.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.45,313.85,
S&N GUIDE 71631626,2109869,CDM,272,RC,,,outpatient,,,312.75,187.65,,234.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,234.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,234.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,197.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.08,281.48,
S&N GUIDE PIN 71751147,2110471,CDM,272,RC,,,outpatient,,,335.46,201.28,,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,301.91,
S&N LONG DRILL BIT 71751149,2110482,CDM,272,RC,,,outpatient,,,485.47,291.28,,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,436.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,305.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,436.92,
S&N PILOT DRILL 71631110,2110918,CDM,272,RC,,,outpatient,,,263.1,157.86,,197.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,197.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,165.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.91,236.79,
SALEM SUMP TUBE 12F,2102939,CDM,272,RC,,,outpatient,,,26.5,15.9,,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,23.85,
SALEM SUMP TUBE 14FR,2112847,CDM,272,RC,,,outpatient,,,26.5,15.9,,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,23.85,
SALEM SUMP TUBE 16F,2108435,CDM,272,RC,,,outpatient,,,6.18,3.71,,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,5.56,
SALEM SUMP TUBE 18F,2102464,CDM,272,RC,,,outpatient,,,12.36,7.42,,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,11.12,
SAME SITE NEEDLE SET 14X25 V9-9204D,2109479,CDM,272,RC,,,outpatient,,,3.72,2.23,,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,3.35,
SAME SITE NEEDLE SET 14X32 V9-9214,2109480,CDM,272,RC,,,outpatient,,,3.72,2.23,,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,3.35,
SCANLAN VASCULAR SHEATH 8MM 12 9009-21,2109656,CDM,272,RC,,,outpatient,,,208.04,124.82,,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,131.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,187.24,
SCARLET RED,2100184,CDM,272,RC,,,outpatient,,,19.63,11.78,,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,17.67,
SCISSOR TIP CURVED DISP LA8000,2109257,CDM,272,RC,,,outpatient,,,353.06,211.84,,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,222.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,317.75,
SELF CATH FEMALE 14FR (240),2108908,CDM,272,RC,,,outpatient,,,4.35,2.61,,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,3.92,
SEROMA CATH WOUND DRAINAGE SYSTEM 1002,2109390,CDM,272,RC,,,outpatient,,,227.99,136.79,,170.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,170.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,170.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.72,205.19,
SEROMA CATH WOUND SYSTEM 1035,2109526,CDM,272,RC,,,outpatient,,,196.41,117.85,,147.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,147.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,147.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,123.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.24,176.77,
SEROMA SAPPHIRE SUCTION RESERVOIR,2112055,CDM,272,RC,,,outpatient,,,101.53,60.92,,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,63.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,91.38,
SHAVER HEAD CUDA C9254,2109763,CDM,272,RC,,,outpatient,,,264.48,158.69,,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.19,238.03,
SHAVER HEADS END CUTTER C9284,2109764,CDM,272,RC,,,outpatient,,,264.48,158.69,,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.19,238.03,
SHEET EXTREMITY 29414,2102886,CDM,272,RC,,,outpatient,,,27.59,16.55,,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,24.83,
SHOE TRAUMA S,2108560,CDM,272,RC,,,outpatient,,,119.11,71.47,,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,107.2,
SHUNT CORATID JAVID 17F,2102962,CDM,272,RC,,,outpatient,,,671.49,402.89,,503.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,537.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,503.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,604.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,503.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,503.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,503.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,503.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,423.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.59,604.34,
SHUNT CORATID LOOP 3.5MMX5MM,2102958,CDM,272,RC,,,outpatient,,,1183.15,709.89,,887.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,946.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,252.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,887.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1064.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,887.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,887.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,887.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,887.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,745.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.43,1064.84,
SHUNT CORATID LOOP 3MMX4MM,2102957,CDM,272,RC,,,outpatient,,,1082.86,649.72,,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,866.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,974.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,682.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.88,974.57,
SHUNT CORATID LOOP 4MMX5MM,2102956,CDM,272,RC,,,outpatient,,,1082.86,649.72,,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,866.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,974.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,682.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.88,974.57,
SHUNT CORATID SUNDT INTERNAL 3.0MMX4.0MM,2102953,CDM,272,RC,,,outpatient,,,926.27,555.76,,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,583.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,833.64,
SHUNT CORATID SUNDT INTERNAL 3.5MMX5MM,2102954,CDM,272,RC,,,outpatient,,,926.27,555.76,,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,583.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,833.64,
SHUNT CORATID SUNDT INTERNAL 4MMX4MM,2102955,CDM,272,RC,,,outpatient,,,926.27,555.76,,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,583.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.79,833.64,
SIGMOID DISP. SPECULA W/OBTURATORS,2102514,CDM,272,RC,,,outpatient,,,17.82,10.69,,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.65,16.04,
SIMPLEX DRILL BIT 1/4X5,2112666,CDM,272,RC,,,outpatient,,,115.83,69.5,,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,104.25,
SIMPLEX DRILL BIT 1/6 X 5 DB-062-5,2112582,CDM,272,RC,,,outpatient,,,115.83,69.5,,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,104.25,
SIMPLEX DRILL BIT 1/8 X5,2113163,CDM,272,RC,,,outpatient,,,80.59,48.35,,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,72.53,
SIMPLEX DRILL BIT 4.8/27 3/16X5,2112583,CDM,272,RC,,,outpatient,,,115.83,69.5,,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,104.25,
SIMPLEX DRILL BIT 5 3/4 X5,2110459,CDM,272,RC,,,outpatient,,,115.83,69.5,,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.73,104.25,
SIMPLEX DRILL BIT 7/64 X5 DB-078-5,2112616,CDM,272,RC,,,outpatient,,,109.05,65.43,,81.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,68.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.34,98.15,
SIMPLEX DRILL BIT 9/64 X5,2113162,CDM,272,RC,,,outpatient,,,80.59,48.35,,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.51,72.53,
SKIN GRAFT KNIFE BROWN,2100347,CDM,272,RC,,,outpatient,,,84.87,50.92,,63.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.39,76.38,
SKIN MARKER 358331145785,2100459,CDM,272,RC,,,outpatient,,,25.41,15.25,,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,22.87,
SKIN MARKER X-FINE POINT 31145942,2111403,CDM,272,RC,,,outpatient,,,25.41,15.25,,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,22.87,
SKIN STAPLER 2025,2111444,CDM,272,RC,,,outpatient,,,293.55,176.13,,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,184.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,264.2,
SKIN STAPLER SIGNET 12,2103275,CDM,272,RC,,,outpatient,,,117.02,70.21,,87.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.98,105.32,
SKIN STAPLER SIGNET 35W,2103007,CDM,272,RC,,,outpatient,,,122.85,73.71,,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.17,110.57,
SLICK SET 3.0 UNCUFFED 150030,2102161,CDM,272,RC,,,outpatient,,,39.61,23.77,,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,35.65,
SLICK SET 3.5 UNCUFFED 150035,2103380,CDM,272,RC,,,outpatient,,,50.82,30.49,,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,45.74,
SLICK SET 4.0 UNCUFFED,2103195,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SLICK SET 4.0 UNCUFFED 150040,2110827,CDM,272,RC,,,outpatient,,,27.8,16.68,,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,25.02,
SLICK SET 4.5 UNCUFFED 150045,2103196,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SLICK SET 5.0,2103197,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SLICK SET 5.5,2103198,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SLICK SET 6.0,2103199,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SLICK SET 6.5,2102330,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SLICK SET 7.0,2102331,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SLICK SET 7.5,2102332,CDM,272,RC,,,outpatient,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.49,24.1,
SLICK SET 8.0,2102333,CDM,272,RC,,,outpatient,,,47.8,28.68,,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,43.02,
SLICK SET 8.5,2101504,CDM,272,RC,,,outpatient,,,124.85,74.91,,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.58,112.37,
SLICK SET 9.0,2103200,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SLICK SET 9.5,2103201,CDM,272,RC,,,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.37,54.34,
SMITH&NEPHEW POINT DRILL 71751149,2110473,CDM,272,RC,,,outpatient,,,485.47,291.28,,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,436.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,305.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,436.92,
SMITH&NEPHEW SHORT DRILL 4.0 71631117,2109870,CDM,272,RC,,,outpatient,,,300.13,180.08,,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,270.12,
SMITH&NEPHEW TROCAR 32MM 71751136,2110472,CDM,272,RC,,,outpatient,,,485.47,291.28,,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,436.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,305.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.47,436.92,
SNARE WIRE DISP. ONLY,2102555,CDM,272,RC,,,outpatient,,,152.44,91.46,,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.23,137.2,
SODIUM CHLORIDE 1500CC BAG,2112484,CDM,272,RC,,,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,39.58,
SODIUM CHLORIDE 3000CC BAG,2109326,CDM,272,RC,,,outpatient,,,101.97,61.18,,76.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.89,91.77,
SODIUM CHLORIDE BAG 1000CC,2112447,CDM,272,RC,,,outpatient,,,68.3,40.98,,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,61.47,
SODIUM CHLORIDE BAG 2000CC,2100871,CDM,272,RC,,,outpatient,,,68.3,40.98,,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,61.47,
SOF-SET,2102217,CDM,272,RC,,,outpatient,,,109.81,65.89,,82.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,98.83,
SOU ORT 1.5MM CRUCIFORM DRIVER,2113061,CDM,272,RC,,,outpatient,,,386.83,232.1,,290.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,290.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,290.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,243.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.26,348.15,
SOU ORT 11MM BUD DRILL DRB1115,2113050,CDM,272,RC,,,outpatient,,,619.04,371.42,,464.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,464.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,557.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,464.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,390,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.84,557.14,
SOU ORT 2.0 DRILL BIT,2113133,CDM,272,RC,,,outpatient,,,286.3,171.78,,214.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,214.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,214.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,180.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.66,257.67,
SOU ORT 2.0 DRILL BIT MS-DCR00,2113054,CDM,272,RC,,,outpatient,,,288.48,173.09,,216.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.11,259.63,
SOU ORT 2.5 DRIVER TIP,2113062,CDM,272,RC,,,outpatient,,,395.57,237.34,,296.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,296.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,249.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.05,356.01,
SOU ORT 2.8 SHORT DRILL,2113187,CDM,272,RC,,,outpatient,,,277.96,166.78,,208.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,208.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,208.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,175.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.95,250.16,
SOU ORT 7.5 LONG DRILL,2113119,CDM,272,RC,,,outpatient,,,601.01,360.61,,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,378.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.15,540.91,
SOU ORT ACU MINI 30MM AT2-M30-S,2111993,CDM,272,RC,,,outpatient,,,1274.68,764.81,,956.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1019.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,956.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1147.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,956.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,803.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.18,1147.21,
SOU ORT ACUTRAK 2 ST DRI BIT AT2-L2515,2111502,CDM,272,RC,,,outpatient,,,677.07,406.24,,507.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,507.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,609.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,507.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,426.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.73,609.36,
SOU ORT ACUTRAK 6/7CAN DRILL AP-67013,2112022,CDM,272,RC,,,outpatient,,,697.33,418.4,,523,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,557.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,523,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,523,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,439.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.88,627.6,
SOU ORT CONCAVE/CONVEX REAMER80-0569/057,2112104,CDM,272,RC,,,outpatient,,,1195.17,717.1,,896.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,896.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,896.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,896.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,896.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,896.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,752.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.89,1075.65,
SOU ORT CONCAVE/CONVEX REAMER80-0573/74,2112528,CDM,272,RC,,,outpatient,,,292.59,175.55,,219.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,219.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,263.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,219.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,184.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.95,263.33,
SOU ORT DRILL 2.0 80-1796,2112687,CDM,272,RC,,,outpatient,,,303.23,181.94,,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,191.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,272.91,
SOU ORT DRILL BIT AP-0100,2111816,CDM,272,RC,,,outpatient,,,683.86,410.32,,512.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,145.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,512.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,615.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,512.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,430.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.12,615.47,
SOU ORT DRILL BIT AT2M-1813,2111692,CDM,272,RC,,,outpatient,,,761.36,456.82,,571.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,571.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,685.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,571.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,571.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,479.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156,685.22,
SOU ORT DRILL BIT LONG ACUTRAK 80-0100,2112344,CDM,272,RC,,,outpatient,,,220.56,132.34,,165.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.19,198.5,
SOU ORT DRILL BIT MICRO 80-0100,2111811,CDM,272,RC,,,outpatient,,,696.69,418.01,,522.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,557.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,522.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,522.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,522.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,522.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,522.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,438.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.75,627.02,
SOU ORT DRILL BIT MS-DC28,2111552,CDM,272,RC,,,outpatient,,,304.06,182.44,,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,191.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.3,273.65,
SOU ORT MINI ACU DRILL BIT AT2-2515,2111805,CDM,272,RC,,,outpatient,,,657.34,394.4,,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,525.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,591.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,414.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.69,591.61,
SOU ORT PROFILE DRILL 7.5,2113118,CDM,272,RC,,,outpatient,,,601.01,360.61,,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,480.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,378.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.15,540.91,
SOU ORT SCREW 3.5MM,2113184,CDM,272,RC,,,outpatient,,,309.78,185.87,,232.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.47,278.8,
SOU ORT SCREW 4.3MM,2113185,CDM,272,RC,,,outpatient,,,316.15,189.69,,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,199.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.78,284.54,
SOU ORT T- HEX DRIVER,2113145,CDM,272,RC,,,outpatient,,,384.05,230.43,,288.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,288.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,288.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,241.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.69,345.65,
SOU ORT T-6 DRIVER TIP 80-1756,2113073,CDM,272,RC,,,outpatient,,,360.6,216.36,,270.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,270.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,270.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,227.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.89,324.54,
SPACE LAB NELCOR NASAL SENSOR,2102950,CDM,272,RC,,,outpatient,,,330.28,198.17,,247.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,247.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,297.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,247.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.67,297.25,
SPACE LAB NELLCOR FINGER SENSOR ADULT,2103028,CDM,272,RC,,,outpatient,,,188.1,112.86,,141.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,118.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.54,169.29,
SPIRE KINK RESIST CATH 28CM XS23SH28,2109483,CDM,272,RC,C1750,HCPCS,outpatient,,,849.56,509.74,,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,679.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,764.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,535.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,764.6,
SPIRE KINK RESIST CATH 32CM XS27SH32,2109482,CDM,272,RC,C1750,HCPCS,outpatient,,,849.56,509.74,,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,679.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,764.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,535.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,764.6,
SPIRE KINK RESIST CATH 36CM XS31SH36,2109481,CDM,272,RC,C1750,HCPCS,outpatient,,,849.56,509.74,,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,679.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,764.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,535.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.07,764.6,
SPIRT ALTA LR CATH AL27NH32,2109660,CDM,272,RC,C1750,HCPCS,outpatient,,,725.97,435.58,,544.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,544.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,653.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,544.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,457.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.75,653.37,
SPLIT DRAPE ORTHO 89331,2109735,CDM,272,RC,,,outpatient,,,28.96,17.38,,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,26.06,
SPORT PACK DUAL LUMEN CATH 8888128485,2109487,CDM,272,RC,,,outpatient,,,628.9,377.34,,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,503.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,566.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,396.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,566.01,
STERI STRIP 1 inch,2108460,CDM,272,RC,,,outpatient,,,34.69,20.81,,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.11,31.22,
STERI STRIP 1/2,2100024,CDM,272,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
STERI STRIP 1/2 PLAIN,2112393,CDM,272,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
STERI STRIP 1/4,2100025,CDM,272,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
STERI STRIP 1/8,2100023,CDM,272,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
STERICAP ASSEMBLY,2101411,CDM,272,RC,,,outpatient,,,10.51,6.31,,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,9.46,
STERICAP STOPCOCK,2101412,CDM,272,RC,,,outpatient,,,3.29,1.97,,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,2.96,
STERILE WATER 1000CC BAG 2B7114X,2112221,CDM,272,RC,,,outpatient,,,5.15,3.09,,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.64,
STERILE WATER 3000CC BAG,2111867,CDM,272,RC,,,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,39.58,
STERILE WATER 500ML,2100140,CDM,272,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
STITCH CUTTER,2109361,CDM,272,RC,,,outpatient,,,2.76,1.66,,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,2.48,
STOCKINETTE STER,2102885,CDM,272,RC,,,outpatient,,,124.55,74.73,,93.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.52,112.1,
STOMACH TUBE 12FR,2100067,CDM,272,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
STOMACH TUBE 14FR,2100066,CDM,272,RC,,,outpatient,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,10.82,
STOMACH TUBE 16FR,2100065,CDM,272,RC,,,outpatient,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,10.82,
STOMACH TUBE 18FR,2100064,CDM,272,RC,,,outpatient,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,10.82,
STOPCOCK DISCOFIX 4 WAY 3584456020,2109551,CDM,272,RC,,,outpatient,,,3.5,2.1,,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.72,3.15,
STOPCOCKS DISP,2100192,CDM,272,RC,,,outpatient,,,9.84,5.9,,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,8.86,
STPLR CEEA 28 111987,2101149,CDM,272,RC,,,outpatient,,,1514.97,908.98,,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1211.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,322.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1363.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,954.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.42,1363.47,
STPLR CEEA 31 111989,2101651,CDM,272,RC,,,outpatient,,,1514.97,908.98,,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1211.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,322.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1363.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1136.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,954.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.42,1363.47,
STPLR DGIA 60 4.8 RELOAD GIA6048L,2112250,CDM,272,RC,,,outpatient,,,439.83,263.9,,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,395.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,277.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.12,395.85,
STPLR DGIA 80 3.8 TITANIUM 031738,2102608,CDM,272,RC,,,outpatient,,,854.24,512.54,,640.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,640.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,640.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,640.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,538.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,175.03,768.82,
STPLR ENDO GIA LG 3.5 030813,2102407,CDM,272,RC,,,outpatient,,,984.2,590.52,,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,209.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,620.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,885.78,
STPLR ENDO GIA LG RELOADER 3.5 030807L,2102405,CDM,272,RC,,,outpatient,,,466.69,280.01,,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,294.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.62,420.02,
STPLR ENDO GIA SM 30V 030811,2102406,CDM,272,RC,,,outpatient,,,984.2,590.52,,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,209.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,620.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.66,885.78,
STPLR ENDO GIA SM RELOADER 30V 030805L,2102404,CDM,272,RC,,,outpatient,,,466.69,280.01,,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,294.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.62,420.02,
STPLR ENDOCLIP 5MM 176620,2109116,CDM,272,RC,,,outpatient,,,1179.4,707.64,,884.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,251.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,251.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,884.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1061.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,884.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,884.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,884.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,884.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,743.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.66,1061.46,
STPLR LDS W/TITANIUM 092001,2102346,CDM,272,RC,,,outpatient,,,954.81,572.89,,716.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,763.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,716.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,859.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,716.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,601.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.64,859.33,
STPLR PURSE STRING 65 020242,2102432,CDM,272,RC,,,outpatient,,,804.52,482.71,,603.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,643.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,603.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,603.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,603.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,506.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.85,724.07,
STPLR RELOAD TA60 4.8,2109842,CDM,272,RC,,,outpatient,,,217.7,130.62,,163.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,163.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,137.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.61,195.93,
STPLR ROTICULATOR 55-3.5 3583017612,2102700,CDM,272,RC,,,outpatient,,,1368.98,821.39,,1026.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1095.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,291.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1026.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1232.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1026.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1026.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1026.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1026.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,862.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.5,1232.08,
STPLR TA 30-3.5 015701,2102460,CDM,272,RC,,,outpatient,,,426.8,256.08,,320.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,320.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,320.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,268.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.45,384.12,
STPLR TA30 3.5 RELOADER,2102401,CDM,272,RC,,,outpatient,,,788.57,473.14,,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,496.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.58,709.71,
STPLR TA30 4.8 RELOADER 015713,2102402,CDM,272,RC,,,outpatient,,,788.57,473.14,,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,709.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,496.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.58,709.71,
STPLR TA55 3.5 RELOADER TIT 015715L,2101977,CDM,272,RC,,,outpatient,,,647.25,388.35,,485.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,485.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,582.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,485.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,407.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.62,582.53,
STR 12 FLUTE B B HOL 5.0 375951112,2111198,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 12 FLUTE BARREL BUR 4.0 375941012,2111189,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 12 FLUTE BARREL BUR 5.5 375951012,2111196,CDM,272,RC,,,outpatient,,,243.69,146.21,,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,153.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.93,219.32,
STR 12 FLUTE ROUND BUR 4.0 375940012,2111186,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 12 FLUTE ROUND BUR 5.0 375950112,2111193,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 12 FLUTE ROUND BUR 5.5 375950012,2111191,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE B B HOL 5.0 375951100,2111197,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE BARREL BUR 4.0 375941000,2111188,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE BARREL BUR 5.5 375951000,2111195,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE EGG BUR 5.5 375952000,2111200,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE ROUND BUR 3.5 375930000,2111151,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE ROUND BUR 4.0 375940000,2111185,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE ROUND BUR 5.0 375950100,2111192,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE ROUND BUR 5.5 375950000,2111153,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE SLAP BUR 4.0 375941500,2111152,CDM,272,RC,,,outpatient,,,125.61,75.37,,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,113.05,
STR 6 FLUTE UNH00D R BUR 4.0 375940200,2111187,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE UNHOOD B B 4.0 375941200,2111190,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR 6 FLUTE UNHOOD B B 5.5 375951200,2111199,CDM,272,RC,,,outpatient,,,243.69,146.21,,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,153.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.93,219.32,
STR 6 FLUTE UNHOOD R BUR 5.5 375950200,2111194,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR ABLATOR 279-351-400,2112354,CDM,272,RC,,,outpatient,,,190.55,114.33,,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,171.5,
STR AGG PLS SHVR BLD INJECT 0375534000,2112357,CDM,272,RC,,,outpatient,,,181.95,109.17,,136.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.28,163.76,
STR AGGRESS PLUS 3.5 CUT 375638000,2111181,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR AGGRESS PLUS 5.0 CUT 375554000,2111145,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR AGGRESS PLUS 5.5 CUT 375564000,2111174,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR AGGRESS PLUS CUT 3.5 375534000,2111160,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR B BUR 12 FLUTE LEFT HELIX 375953012,2111202,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR B BUR 6 FLUTE LEFT HELIX 375953000,2111201,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR BARREL BUR 5.0 0375-951-100,2112346,CDM,272,RC,,,outpatient,,,252.14,151.28,,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.66,226.93,
STR COUGAR CUTTER 4.0MM 375-541-000,2111162,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR COUGAR CUTTER 5.0MM 375-551-000,2111170,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR DBL BITE CUTTER 4.0MM 375-543-000,2111164,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR END CUTTER 3.5 375737000,2111183,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR END CUTTER 4.0 375747000,2111148,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR END CUTTER 5.0 375757000,2111184,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR ENDO ACL PACK 234-020-280,2112778,CDM,272,RC,,,outpatient,,,1134.25,680.55,,850.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,907.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1020.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,850.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,714.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.41,1020.83,
STR FLOSTEADY TUBE SET 350800006,2111158,CDM,272,RC,,,outpatient,,,127.41,76.45,,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.11,114.67,
STR FLOW 2 250070520,2111154,CDM,272,RC,,,outpatient,,,120.52,72.31,,90.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,108.47,
STR FLOWSTE AGGR PLUS 4.0 CUT 375544000,2111165,CDM,272,RC,,,outpatient,,,151.81,91.09,,113.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.11,136.63,
STR HEATED TUBESET 0620-040-690,2111155,CDM,272,RC,,,outpatient,,,116.39,69.83,,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.85,104.75,
STR ORT 8MM CANNULA 3910-075-800,2112752,CDM,272,RC,,,outpatient,,,119.39,71.63,,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,107.45,
STR ORT CINCHLOCK DRILL CAT02463,2112750,CDM,272,RC,,,outpatient,,,389.34,233.6,,292.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,292.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,292.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,245.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.78,350.41,
STR ORT CINCHLOCK FLEX BIT CAT02644,2112756,CDM,272,RC,,,outpatient,,,417.97,250.78,,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,376.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,263.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,376.17,
STR ORT DRILL 1806-3540S,2112572,CDM,272,RC,,,outpatient,,,465.23,279.14,,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.33,418.71,
STR ORT DRILL 1806-4260S,2112498,CDM,272,RC,,,outpatient,,,491.19,294.71,,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,442.07,
STR ORT DRILL 1806-4280S,2111948,CDM,272,RC,,,outpatient,,,442.55,265.53,,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,398.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.68,398.3,
STR ORT DRILL 1806-5000S,2111647,CDM,272,RC,,,outpatient,,,491.19,294.71,,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,442.07,
STR ORT DRILL 4.3X262 702743,2112801,CDM,272,RC,,,outpatient,,,311.98,187.19,,233.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,233.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,233.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.92,280.78,
STR ORT DRILL BIT,2112612,CDM,272,RC,,,outpatient,,,1023.91,614.35,,767.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,218.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,767.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,921.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,767.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,645.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.8,921.52,
STR ORT DRILL BIT 1320-0190,2113141,CDM,272,RC,,,outpatient,,,2063.16,1237.9,,1547.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1650.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,439.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,439.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1547.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1856.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1547.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1547.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1547.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1547.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1299.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.74,1856.84,
STR ORT DRILL BIT 1320-3047S/42S,2111547,CDM,272,RC,,,outpatient,,,458.29,274.97,,343.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,366.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,343.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,343.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,288.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.9,412.46,
STR ORT DRILL BIT 5085-2-032,2112764,CDM,272,RC,,,outpatient,,,225.11,135.07,,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,202.6,
STR ORT DRILL BIT CANN 3.5,2112802,CDM,272,RC,,,outpatient,,,709.22,425.53,,531.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,567.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,531.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,638.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,531.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,446.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.32,638.3,
STR ORT DRILL BIT CANN 3.5,2112854,CDM,272,RC,,,outpatient,,,512.21,307.33,,384.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,384.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,384.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,384.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,322.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.95,460.99,
STR ORT DRILL GUIDE WIR 1806-3550S,2111956,CDM,272,RC,,,outpatient,,,465.23,279.14,,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.33,418.71,
STR ORT GRAY REV INST SYS OSTEOTOME,2112743,CDM,272,RC,,,outpatient,,,902.59,541.55,,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,812.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,568.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.94,812.33,
STR ORT GUIDE WIRE,2111532,CDM,272,RC,,,outpatient,,,493.64,296.18,,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,444.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,310.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.15,444.28,
STR ORT GUIDE WIRE BALL T,2111614,CDM,272,RC,,,outpatient,,,442.55,265.53,,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,398.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.68,398.3,
STR ORT HYDROSET XT,2113003,CDM,272,RC,,,outpatient,,,3192.4,1915.44,,2394.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2553.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,679.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,679.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2394.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,686.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2873.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2394.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2394.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2394.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2394.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2011.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.12,2873.16,
STR ORT RP 360 DEGREE FLEX NEEDLE 3910-9,2112748,CDM,272,RC,,,outpatient,,,358.14,214.88,,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,225.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.38,322.33,
STR ORT RP F FIBER SUT 3910-900-022,2112836,CDM,272,RC,,,outpatient,,,104.36,62.62,,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,93.92,
STR ORT SHOULDER DRILL BIT 5901-1126,2112707,CDM,272,RC,,,outpatient,,,608.96,365.38,,456.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,487.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,456.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,548.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,456.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,383.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.78,548.06,
STR ORT SHOULDER DRILL BIT 5901-1126,2112729,CDM,272,RC,,,outpatient,,,187.94,112.76,,140.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,140.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,118.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.51,169.15,
STR ORT TEFLON TUBE ST 1806-0073S,2111617,CDM,272,RC,,,outpatient,,,596.63,357.98,,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,536.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,375.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.25,536.97,
STR ORT TEFLON TUBE ST 1806-0073S,2112722,CDM,272,RC,,,outpatient,,,568.5,341.1,,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,358.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.49,511.65,
STR ORT UNIV CEM RESTRICTOR,2111829,CDM,272,RC,,,outpatient,,,313.89,188.33,,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,197.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,282.5,
STR RESECTOR CUTTER 3.5 375-532-000,2111159,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR RESECTOR CUTTER 4.0 375-542-000,2111163,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR RESECTOR CUTTER 5.0 375-552-000,2111171,CDM,272,RC,,,outpatient,,,113.92,68.35,,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,102.53,
STR RESECTOR CUTTER 5.5 375562000,2111173,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR RF 2 PROBE MICROBRUSH 0279250201,2112356,CDM,272,RC,,,outpatient,,,357.05,214.23,,267.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,267.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,224.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.16,321.35,
STR SAGITTAL BLADE 6118127090,2112868,CDM,272,RC,,,outpatient,,,287.39,172.43,,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.89,258.65,
STR SAGITTAL BLADE 6125-127-090,2112872,CDM,272,RC,,,outpatient,,,287.39,172.43,,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.89,258.65,
STR SCALLOPED CUTTER 4.0 375-546-000,2111167,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR SCALLOPED CUTTER 5.5 375566000,2111176,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR SCOPE CAMERA WARMER 502360000,2111220,CDM,272,RC,,,outpatient,,,80.31,48.19,,60.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,72.28,
STR SER ENER PROBE 90-s 3.5 279351100,2111557,CDM,272,RC,,,outpatient,,,416.19,249.71,,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,374.57,
STR SER ENER PROBE HOOK 3.5 279350501,2111556,CDM,272,RC,,,outpatient,,,397.62,238.57,,298.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,298.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,357.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,250.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.47,357.86,
STR SERFAS ENERGY PRO 50S 3.5 279351250,2111157,CDM,272,RC,,,outpatient,,,246.77,148.06,,185.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,185.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.56,222.09,
STR SLOT WHIS CUTTER 4.0 375-548-000,2111168,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR SLOT WHIS CUTTER 5.0 375558000,2111146,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR SM JOINT AGGRESS 2.5 CUT 375628000,2111177,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR SM JOINT AGGRESS 3.5 CUT 375636000,2111179,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR SM JOINT FULL RAD 2.5 CUT 375627000,2111178,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR SM JOINT FULL RAD 3.5 CUT 375637000,2111180,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR SM JOINT HOOD ABR 2.0 375641000,2111147,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR SM JOINT HOOD ABR 3.0 375647000,2111182,CDM,272,RC,,,outpatient,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.15,101.69,
STR SPATULA TIP 45CM 250070451,2111208,CDM,272,RC,,,outpatient,,,730.54,438.32,,547.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,547.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,657.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,547.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,547.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,460.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.69,657.49,
STR SUBCHONDRAL DRILL 4.0MM 375832000,2111149,CDM,272,RC,,,outpatient,,,125.61,75.37,,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,113.05,
STR TOM CAT 5.0 0375555000,2111172,CDM,272,RC,,,outpatient,,,75.19,45.11,,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,67.67,
STR TOM CAT CUTTER 4.0 375545000,2111166,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR TOM CAT CUTTER 5.5 375565000,2111175,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STR TOM CAT SHAVER 3.5 375535000,2111161,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STR TRUE END CUTTER 4.0 375884000,2111150,CDM,272,RC,,,outpatient,,,184.6,110.76,,138.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.82,166.14,
STR W/O TIP 250-070-500,2111219,CDM,272,RC,,,outpatient,,,118.45,71.07,,88.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.27,106.61,
STR W/TIP 25-0070-520,2111218,CDM,272,RC,,,outpatient,,,171.44,102.86,,128.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,108.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.13,154.3,
STR WHIS CUTTER 4.0MM 375-549-000,2111169,CDM,272,RC,,,outpatient,,,106.93,64.16,,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.91,96.24,
STRYKER ART TUB INFLOW 450-000-100,2112352,CDM,272,RC,,,outpatient,,,146.26,87.76,,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.97,131.63,
STRYKER ARTH TUBING O FLOW 450-000-200,2112353,CDM,272,RC,,,outpatient,,,146.26,87.76,,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.97,131.63,
STRYKER AUGER BUR 5.0MM 0375-450-500,2111143,CDM,272,RC,,,outpatient,,,125.61,75.37,,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.74,113.05,
STRYKER COUGAR CUTTER 3.5MM 0375-531-000,2111144,CDM,272,RC,,,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,96.63,
STRYKER ENDO SHEATH 502110116,2111870,CDM,272,RC,,,outpatient,,,147.57,88.54,,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,132.81,
STRYKER GUIDE WIRE 1.4MM 702459,2109864,CDM,272,RC,,,outpatient,,,279.55,167.73,,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,251.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,176.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.28,251.6,
STRYKER K WIRE,2110469,CDM,272,RC,,,outpatient,,,286.87,172.12,,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,180.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.78,258.18,
STRYKER MINI GRASPER 255000001,2111713,CDM,272,RC,,,outpatient,,,464.46,278.68,,348.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.17,418.01,
STRYKER ORT CEMENT RESTRICTOR B000-0240,2112449,CDM,272,RC,,,outpatient,,,2094.32,1256.59,,1570.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1675.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,446.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1570.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1884.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1570.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1319.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.13,1884.89,
STRYKER ORT DRILL 02713203042SOL,2111681,CDM,272,RC,,,outpatient,,,416.19,249.71,,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,374.57,
STRYKER ORT DRILL 02718036420SOW,2111755,CDM,272,RC,,,outpatient,,,416.19,249.71,,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.28,374.57,
STRYKER ORT DRILL 02718063550SOY,2111684,CDM,272,RC,,,outpatient,,,431.36,258.82,,323.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,323.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,323.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,271.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.39,388.22,
STRYKER ORT GUIDE WIRE BALL,2111646,CDM,272,RC,,,outpatient,,,408.55,245.13,,306.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,257.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.71,367.7,
STRYKER SUCT. IRRIGATOR 250-070-520,2111106,CDM,272,RC,,,outpatient,,,102.91,61.75,,77.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.09,92.62,
STYLETTE LIGHTED INTIBATING 9-0210-01,2102977,CDM,272,RC,,,outpatient,,,355.96,213.58,,266.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,266.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,266.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,224.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.94,320.36,
SUPER REVO KIT SMM C6140H,2110305,CDM,272,RC,,,outpatient,,,386.17,231.7,,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,243.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.13,347.55,
SUPER SUCKER LONG STRAIGHT SS1,2109907,CDM,272,RC,,,outpatient,,,90.07,54.04,,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.46,81.06,
SUPER SUCKER SHORT STRAIGHT SS2C,2109906,CDM,272,RC,,,outpatient,,,90.07,54.04,,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.46,81.06,
SURECAN SAFETY HUBER NEEDLE 471745,2109371,CDM,272,RC,,,outpatient,,,37.15,22.29,,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,33.44,
SURG GLOVE 8 NEUT,2101469,CDM,272,RC,,,outpatient,,,26.31,15.79,,19.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.39,23.68,
SURGE PRO BENTSON GUIDEWIRE SGW-035-07,2109661,CDM,272,RC,C1769,HCPCS,outpatient,,,147.15,88.29,,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,132.44,
SURGE PRO BENTSON GUIDEWIRE SGW-035-07,2109664,CDM,272,RC,C1769,HCPCS,outpatient,,,147.15,88.29,,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,132.44,
SURGE PRO DECATHLON 50CM/55CM DE50SH55,2109649,CDM,272,RC,C1750,HCPCS,outpatient,,,761.3,456.78,,570.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,570.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,685.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,570.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,479.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.99,685.17,
SURGE PRO ELIMINATOR EL10060060,2109584,CDM,272,RC,,,outpatient,,,871.64,522.98,,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,697.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,784.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,549.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.6,784.48,
SURGI-KIT ETHOX,2108574,CDM,272,RC,,,outpatient,,,24.32,14.59,,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.98,21.89,
SURGICAL INST,2100433,CDM,272,RC,,,outpatient,,,18.99,11.39,,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,17.09,
SURGICEL 2/14,2100112,CDM,272,RC,,,outpatient,,,240.95,144.57,,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,216.86,
SURGICEL NU-KNIT 3X4 1943,2108966,CDM,272,RC,,,outpatient,,,376.71,226.03,,282.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,282.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,237.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.19,339.04,
SURGIFISH VISCERA RETAINER,2103015,CDM,272,RC,,,outpatient,,,131.13,78.68,,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.87,118.02,
SURGITIE CHROMIC GUT LIGATING LOOP,2102292,CDM,272,RC,,,outpatient,,,267.72,160.63,,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,240.95,
SURGITIE PLAIN GUT LIGATING LOOP,2102607,CDM,272,RC,,,outpatient,,,197.65,118.59,,148.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,124.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.5,177.89,
SUTURE 1 TICRON,2111538,CDM,272,RC,,,outpatient,,,23.23,13.94,,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.76,20.91,
SUTURE 1614G,2108540,CDM,272,RC,,,outpatient,,,55.81,33.49,,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,50.23,
SUTURE 1615G,2108541,CDM,272,RC,,,outpatient,,,55.81,33.49,,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.44,50.23,
SUTURE 1658G 6-0 GUT CHR,2101895,CDM,272,RC,,,outpatient,,,65.35,39.21,,49.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.39,58.82,
SUTURE 1663G,2109726,CDM,272,RC,,,outpatient,,,39.61,23.77,,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,35.65,
SUTURE 1665G,2102508,CDM,272,RC,,,outpatient,,,61.21,36.73,,45.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.54,55.09,
SUTURE 1667H,2109066,CDM,272,RC,,,outpatient,,,46.46,27.88,,34.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.52,41.81,
SUTURE 1668G 5.0 ETHILON,2111427,CDM,272,RC,,,outpatient,,,26.52,15.91,,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,23.87,
SUTURE 1674H,2109612,CDM,272,RC,,,outpatient,,,16.76,10.06,,12.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.43,15.08,
SUTURE 1677G,2109752,CDM,272,RC,,,outpatient,,,35.97,21.58,,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.37,32.37,
SUTURE 1698G 6-0 ETHILON,2101871,CDM,272,RC,,,outpatient,,,20.58,12.35,,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.52,
SUTURE 1716G,2109901,CDM,272,RC,,,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.37,120.23,
SUTURE 1824H,2103370,CDM,272,RC,,,outpatient,,,28.33,17,,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,25.5,
SUTURE 1864G,2103799,CDM,272,RC,,,outpatient,,,79.23,47.54,,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,71.31,
SUTURE 1865H,2101799,CDM,272,RC,,,outpatient,,,72.56,43.54,,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.87,65.3,
SUTURE 1866G,2100975,CDM,272,RC,,,outpatient,,,73.84,44.3,,55.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.13,66.46,
SUTURE 1915G,2103372,CDM,272,RC,,,outpatient,,,66.84,40.1,,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.7,60.16,
SUTURE 1916G,2103289,CDM,272,RC,,,outpatient,,,67.05,40.23,,50.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.74,60.35,
SUTURE 1955G,2103373,CDM,272,RC,,,outpatient,,,73.74,44.24,,55.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.11,66.37,
SUTURE 3274-61 CV300,2108628,CDM,272,RC,,,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,65.64,
SUTURE 450G RETENTION BOLSTER,2102420,CDM,272,RC,,,outpatient,,,27.04,16.22,,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,24.34,
SUTURE 47T,2102639,CDM,272,RC,,,outpatient,,,74.8,44.88,,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.33,67.32,
SUTURE 489T 1 ETHILON,2101859,CDM,272,RC,,,outpatient,,,39.61,23.77,,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,35.65,
SUTURE 48G*,2102640,CDM,272,RC,,,outpatient,,,106.81,64.09,,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.89,96.13,
SUTURE 490T,2102419,CDM,272,RC,,,outpatient,,,42.97,25.78,,32.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.8,38.67,
SUTURE 583H,2109385,CDM,272,RC,,,outpatient,,,33.1,19.86,,24.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.78,29.79,
SUTURE 621H 4-0 SILK,2101861,CDM,272,RC,,,outpatient,,,20.76,12.46,,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,18.68,
SUTURE 622H 3-0 SILK,2101862,CDM,272,RC,,,outpatient,,,25.13,15.08,,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,22.62,
SUTURE 623H,2101863,CDM,272,RC,,,outpatient,,,20.76,12.46,,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.25,18.68,
SUTURE 624H,2111409,CDM,272,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
SUTURE 635H 4-0 GUT CHR,2101864,CDM,272,RC,,,outpatient,,,22.4,13.44,,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,20.16,
SUTURE 636H 3-0 GUT CHR,2101865,CDM,272,RC,,,outpatient,,,27.69,16.61,,20.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.67,24.92,
SUTURE 637H 2-0 GUT CHR,2101866,CDM,272,RC,,,outpatient,,,24.85,14.91,,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,22.37,
SUTURE 640G 5-0 SILK 230000640G,2101927,CDM,272,RC,,,outpatient,,,36.49,21.89,,27.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.48,32.84,
SUTURE 661G,2102098,CDM,272,RC,,,outpatient,,,18.57,11.14,,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.71,
SUTURE 661H 5-0 ETHILON,2101867,CDM,272,RC,,,outpatient,,,62.01,37.21,,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,55.81,
SUTURE 662G 4-0 ETHILON,2101868,CDM,272,RC,,,outpatient,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,24.59,
SUTURE 662H 4.0 ETHILON,2101869,CDM,272,RC,,,outpatient,,,14.42,8.65,,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,12.98,
SUTURE 663G 3-0 ETHILON,2101870,CDM,272,RC,,,outpatient,,,27.59,16.55,,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,24.83,
SUTURE 663H 3-0 ETHILON,2101894,CDM,272,RC,,,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,6.49,
SUTURE 664H 2-0 ETHILON*,2101898,CDM,272,RC,,,outpatient,,,38.11,22.87,,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.81,34.3,
SUTURE 667H,2108959,CDM,272,RC,,,outpatient,,,19.84,11.9,,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,17.86,
SUTURE 668G,2101872,CDM,272,RC,,,outpatient,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,24.59,
SUTURE 678H 0 SILK,2101873,CDM,272,RC,,,outpatient,,,25.04,15.02,,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,22.54,
SUTURE 679H 2-0 SILK*,2101874,CDM,272,RC,,,outpatient,,,16.67,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,15,
SUTURE 683G,2101875,CDM,272,RC,,,outpatient,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.6,24.59,
SUTURE 684H 3-0 SILK,2101897,CDM,272,RC,,,outpatient,,,25.25,15.15,,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,22.73,
SUTURE 698H,2108937,CDM,272,RC,,,outpatient,,,48.7,29.22,,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,43.83,
SUTURE 699H,2108938,CDM,272,RC,,,outpatient,,,48.7,29.22,,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.98,43.83,
SUTURE 711G 6-0 SILK,2101876,CDM,272,RC,,,outpatient,,,20.58,12.35,,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.52,
SUTURE 723G 5-0 GUT CHR,2101877,CDM,272,RC,,,outpatient,,,59.55,35.73,,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.2,53.6,
SUTURE 725G,2108942,CDM,272,RC,,,outpatient,,,264.27,158.56,,198.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.15,237.84,
SUTURE 740G 5-0 MERSELINE,2109363,CDM,272,RC,,,outpatient,,,104.81,62.89,,78.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.48,94.33,
SUTURE 744G,2103371,CDM,272,RC,,,outpatient,,,48.16,28.9,,36.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,43.34,
SUTURE 7700G,2108771,CDM,272,RC,,,outpatient,,,185.55,111.33,,139.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.02,167,
SUTURE 790G 6-0 CHROMIC,2108803,CDM,272,RC,,,outpatient,,,147.57,88.54,,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.24,132.81,
SUTURE 796G 6-0 GUT CHR,2101878,CDM,272,RC,,,outpatient,,,70.48,42.29,,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,63.43,
SUTURE 800H 3-0 GUT CHR,2101879,CDM,272,RC,,,outpatient,,,28.22,16.93,,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,25.4,
SUTURE 801H 2-0 GUT CHR,2101880,CDM,272,RC,,,outpatient,,,28.22,16.93,,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,25.4,
SUTURE 802H 0 GUT CHR,2101881,CDM,272,RC,,,outpatient,,,28.22,16.93,,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,25.4,
SUTURE 811H,2101882,CDM,272,RC,,,outpatient,,,18.99,11.39,,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,17.09,
SUTURE 812H,2101883,CDM,272,RC,,,outpatient,,,20.37,12.22,,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,18.33,
SUTURE 813H,2102603,CDM,272,RC,,,outpatient,,,25.04,15.02,,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,22.54,
SUTURE 8305H,2102911,CDM,272,RC,,,outpatient,,,191.7,115.02,,143.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.28,172.53,
SUTURE 8318H,2102525,CDM,272,RC,,,outpatient,,,114.26,68.56,,85.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.41,102.83,
SUTURE 832H 3-0 GUT CHR,2101884,CDM,272,RC,,,outpatient,,,30.13,18.08,,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,27.12,
SUTURE 833H 0 GUT CHR,2101943,CDM,272,RC,,,outpatient,,,47.27,28.36,,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.69,42.54,
SUTURE 8412H 0 PROLENE,2101950,CDM,272,RC,,,outpatient,,,29.5,17.7,,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.04,26.55,
SUTURE 8425H,2109013,CDM,272,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
SUTURE 842H 3-0 GUT PL,2101923,CDM,272,RC,,,outpatient,,,22.13,13.28,,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,19.92,
SUTURE 843H,2102854,CDM,272,RC,,,outpatient,,,27.8,16.68,,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,25.02,
SUTURE 8454H CTX,2112287,CDM,272,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
SUTURE 8455H CTX,2112286,CDM,272,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
SUTURE 8556H 5-0 PROLENE,2101920,CDM,272,RC,,,outpatient,,,45.35,27.21,,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,40.82,
SUTURE 855H,2102071,CDM,272,RC,,,outpatient,,,21.86,13.12,,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,19.67,
SUTURE 8571G,2102546,CDM,272,RC,,,outpatient,,,81.37,48.82,,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.67,73.23,
SUTURE 8619G,2109384,CDM,272,RC,,,outpatient,,,51.91,31.15,,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,46.72,
SUTURE 862H,2108713,CDM,272,RC,,,outpatient,,,26.74,16.04,,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,24.07,
SUTURE 8634G PROLENE*,2113144,CDM,272,RC,,,outpatient,,,46.21,27.73,,34.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.47,41.59,
SUTURE 8634G*,2112237,CDM,272,RC,,,outpatient,,,18.25,10.95,,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.74,16.43,
SUTURE 863H 2-0 GUT CHR,2101904,CDM,272,RC,,,outpatient,,,20.37,12.22,,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,18.33,
SUTURE 8683G,2109155,CDM,272,RC,,,outpatient,,,5.73,3.44,,4.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.17,5.16,
SUTURE 8685H,2111819,CDM,272,RC,,,outpatient,,,36.06,21.64,,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,32.45,
SUTURE 8700H 7-0 PROLENE,2101891,CDM,272,RC,,,outpatient,,,60.15,36.09,,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.32,54.14,
SUTURE 8701H,2102892,CDM,272,RC,,,outpatient,,,162.64,97.58,,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.32,146.38,
SUTURE 8756H,2102524,CDM,272,RC,,,outpatient,,,71.82,43.09,,53.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.72,64.64,
SUTURE 8806H,2109343,CDM,272,RC,,,outpatient,,,162.64,97.58,,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.32,146.38,
SUTURE 8806H*,2109337,CDM,272,RC,,,outpatient,,,177.84,106.7,,133.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,112.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.44,160.06,
SUTURE 8824G,2101135,CDM,272,RC,,,outpatient,,,59.31,35.59,,44.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.15,53.38,
SUTURE 882H 3-0 GUT CHR,2101885,CDM,272,RC,,,outpatient,,,28.22,16.93,,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.78,25.4,
SUTURE 8831H*,2101165,CDM,272,RC,,,outpatient,,,39.61,23.77,,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,35.65,
SUTURE 8832H,2101361,CDM,272,RC,,,outpatient,,,39.61,23.77,,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,35.65,
SUTURE 8833H,2102509,CDM,272,RC,,,outpatient,,,38.52,23.11,,28.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,34.67,
SUTURE 883H 2-0 GUT CHR,2101886,CDM,272,RC,,,outpatient,,,30.87,18.52,,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,27.78,
SUTURE 8845G 1 PROLENE,2102384,CDM,272,RC,,,outpatient,,,54.53,32.72,,40.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,49.08,
SUTURE 884H 0 GUT CHR,2101887,CDM,272,RC,,,outpatient,,,30.87,18.52,,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,27.78,
SUTURE 885H,2102593,CDM,272,RC,,,outpatient,,,75.32,45.19,,56.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.43,67.79,
SUTURE 8862H 3-0 PROLENE,2102317,CDM,272,RC,,,outpatient,,,66.84,40.1,,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.7,60.16,
SUTURE 8889H 6-0 PROLENE,2101952,CDM,272,RC,,,outpatient,,,56.55,33.93,,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.59,50.9,
SUTURE 9032G,2108770,CDM,272,RC,,,outpatient,,,210.06,126.04,,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,132.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.04,189.05,
SUTURE 905H,2102599,CDM,272,RC,,,outpatient,,,34.27,20.56,,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,30.84,
SUTURE 912H,2109299,CDM,272,RC,,,outpatient,,,23.76,14.26,,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,21.38,
SUTURE 921H 4-0 GUT CHR,2101888,CDM,272,RC,,,outpatient,,,18.35,11.01,,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.76,16.52,
SUTURE 922H 3-0 GUT CHR,2101909,CDM,272,RC,,,outpatient,,,22.6,13.56,,16.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,20.34,
SUTURE 923H 2-0 GUT CHR,2101903,CDM,272,RC,,,outpatient,,,23.76,14.26,,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,21.38,
SUTURE 924H 0 GUT CHR,2101947,CDM,272,RC,,,outpatient,,,31.19,18.71,,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.39,28.07,
SUTURE 973H 2-0 GUT CHR,2101902,CDM,272,RC,,,outpatient,,,30.13,18.08,,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,27.12,
SUTURE A183H,2109910,CDM,272,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
SUTURE A184H,2103092,CDM,272,RC,,,outpatient,,,25.41,15.25,,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,22.87,
SUTURE A185H,2103093,CDM,272,RC,,,outpatient,,,25.41,15.25,,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.21,22.87,
SUTURE A186H,2103094,CDM,272,RC,,,outpatient,,,35.78,21.47,,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,32.2,
SUTURE BONE WAX W-31G,2100493,CDM,272,RC,,,outpatient,,,28.01,16.81,,21.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.74,25.21,
SUTURE C003D 3-0 SILK,2101918,CDM,272,RC,,,outpatient,,,105.72,63.43,,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.66,95.15,
SUTURE C004T,2101801,CDM,272,RC,,,outpatient,,,129.65,77.79,,97.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.57,116.69,
SUTURE C012D,2109015,CDM,272,RC,,,outpatient,,,142.33,85.4,,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,89.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.16,128.1,
SUTURE C016T 2-0 SILK,2101928,CDM,272,RC,,,outpatient,,,109.55,65.73,,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.45,98.6,
SUTURE C027D*,2102466,CDM,272,RC,,,outpatient,,,119.11,71.47,,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.41,107.2,
SUTURE CO17T 3-0 SILK,2101802,CDM,272,RC,,,outpatient,,,148.95,89.37,,111.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.52,134.06,
SUTURE CO21D O SILK CR,2102428,CDM,272,RC,,,outpatient,,,159.45,95.67,,119.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.67,143.51,
SUTURE CX45D,2102874,CDM,272,RC,,,outpatient,,,266.63,159.98,,199.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,199.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,167.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.63,239.97,
SUTURE G113H 2-0 GUT CHR,2101939,CDM,272,RC,,,outpatient,,,23.12,13.87,,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,20.81,
SUTURE G121H 4-0 GUT CHR,2101910,CDM,272,RC,,,outpatient,,,23.12,13.87,,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.74,20.81,
SUTURE G122H,2108407,CDM,272,RC,,,outpatient,,,27.8,16.68,,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,25.02,
SUTURE G123H 2-0 GUT CHROMIC,2101805,CDM,272,RC,,,outpatient,,,30.87,18.52,,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,27.78,
SUTURE G124H 0 GUT CHR SH,2101806,CDM,272,RC,,,outpatient,,,18.99,11.39,,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,17.09,
SUTURE G182H 3-0 GUT CHR*,2101807,CDM,272,RC,,,outpatient,,,30.87,18.52,,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,27.78,
SUTURE G321H 4-0 GUT PL,2101924,CDM,272,RC,,,outpatient,,,17.08,10.25,,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,15.37,
SUTURE G666G 5-0 ETHILON,2101808,CDM,272,RC,,,outpatient,,,62.49,37.49,,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,56.24,
SUTURE G698G 5-0 ETHILON,2101810,CDM,272,RC,,,outpatient,,,40.63,24.38,,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.33,36.57,
SUTURE J109T,2102856,CDM,272,RC,,,outpatient,,,140.36,84.22,,105.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.76,126.32,
SUTURE J110T,2102855,CDM,272,RC,,,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,132.28,
SUTURE J111T,2102926,CDM,272,RC,,,outpatient,,,160.09,96.05,,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,144.08,
SUTURE J214H 4-0 CO VIC*,2101900,CDM,272,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
SUTURE J218H,2109042,CDM,272,RC,,,outpatient,,,24.72,14.83,,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.07,22.25,
SUTURE J275H 2-0 CO VIC,2101929,CDM,272,RC,,,outpatient,,,21.54,12.92,,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,19.39,
SUTURE J303H 5-0 CO VIC,2101814,CDM,272,RC,,,outpatient,,,26.2,15.72,,19.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,23.58,
SUTURE J304H 4-0 CO VIC,2101815,CDM,272,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
SUTURE J311H 3-0 CO VIC,2101816,CDM,272,RC,,,outpatient,,,25.95,15.57,,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,23.36,
SUTURE J315H,2102468,CDM,272,RC,,,outpatient,,,28.64,17.18,,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.87,25.78,
SUTURE J316H*,2112361,CDM,272,RC,,,outpatient,,,6.28,3.77,,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,5.65,
SUTURE J317H,2109045,CDM,272,RC,,,outpatient,,,24.18,14.51,,18.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.95,21.76,
SUTURE J332H,2102617,CDM,272,RC,,,outpatient,,,27.8,16.68,,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,25.02,
SUTURE J333H,2108586,CDM,272,RC,,,outpatient,,,31.96,19.18,,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.55,28.76,
SUTURE J334H,2108588,CDM,272,RC,,,outpatient,,,34.42,20.65,,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.05,30.98,
SUTURE J337H,2102467,CDM,272,RC,,,outpatient,,,26.1,15.66,,19.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.35,23.49,
SUTURE J340H,2109031,CDM,272,RC,,,outpatient,,,28.96,17.38,,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.93,26.06,
SUTURE J344H 3-0 CO VIC,2101819,CDM,272,RC,,,outpatient,,,27.59,16.55,,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,24.83,
SUTURE J345H,2102606,CDM,272,RC,,,outpatient,,,29.71,17.83,,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,26.74,
SUTURE J346H 0 CO VIC,2101948,CDM,272,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
SUTURE J347H 1 VICRYL,2102383,CDM,272,RC,,,outpatient,,,30.55,18.33,,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.26,27.5,
SUTURE J371H,2109720,CDM,272,RC,,,outpatient,,,16.02,9.61,,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,14.42,
SUTURE J376H,2103260,CDM,272,RC,,,outpatient,,,39.89,23.93,,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.17,35.9,
SUTURE J415H,2109708,CDM,272,RC,,,outpatient,,,18.57,11.14,,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.71,
SUTURE J416H,2102908,CDM,272,RC,,,outpatient,,,78.28,46.97,,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,70.45,
SUTURE J417H*,2109047,CDM,272,RC,,,outpatient,,,61.8,37.08,,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,55.62,
SUTURE J422H*,2102594,CDM,272,RC,,,outpatient,,,30.6,18.36,,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,27.54,
SUTURE J423H,2102592,CDM,272,RC,,,outpatient,,,28.12,16.87,,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,25.31,
SUTURE J436H,2102591,CDM,272,RC,,,outpatient,,,37.55,22.53,,28.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.69,33.8,
SUTURE J442H 3-0 CO VIC,2101821,CDM,272,RC,,,outpatient,,,25.95,15.57,,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,23.36,
SUTURE J443H*,2110789,CDM,272,RC,,,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,6.49,
SUTURE J459H,2109969,CDM,272,RC,,,outpatient,,,30.06,18.04,,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.16,27.05,
SUTURE J466H,2109046,CDM,272,RC,,,outpatient,,,26.74,16.04,,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,24.07,
SUTURE J478H,2109723,CDM,272,RC,,,outpatient,,,20.16,12.1,,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,18.14,
SUTURE J479H,2109722,CDM,272,RC,,,outpatient,,,20.16,12.1,,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,18.14,
SUTURE J480H,2109721,CDM,272,RC,,,outpatient,,,20.16,12.1,,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,18.14,
SUTURE J490G,2110589,CDM,272,RC,,,outpatient,,,37.45,22.47,,28.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.67,33.71,
SUTURE J494G,2109724,CDM,272,RC,,,outpatient,,,43.44,26.06,,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.9,39.1,
SUTURE J496G 4-0 CO VIC,2101822,CDM,272,RC,,,outpatient,,,60.47,36.28,,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.39,54.42,
SUTURE J503G,2108880,CDM,272,RC,,,outpatient,,,56.23,33.74,,42.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.52,50.61,
SUTURE J504G,2108822,CDM,272,RC,,,outpatient,,,59.63,35.78,,44.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.22,53.67,
SUTURE J518H 0 CO VIC,2101823,CDM,272,RC,,,outpatient,,,38.51,23.11,,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.89,34.66,
SUTURE J544G 6-0 CO VIC,2101896,CDM,272,RC,,,outpatient,,,216.42,129.85,,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,136.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.34,194.78,
SUTURE J546G,2108772,CDM,272,RC,,,outpatient,,,133.03,79.82,,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.26,119.73,
SUTURE J576G,2108881,CDM,272,RC,,,outpatient,,,190.96,114.58,,143.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.13,171.86,
SUTURE J581G,2108714,CDM,272,RC,,,outpatient,,,60.79,36.47,,45.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.46,54.71,
SUTURE J589H,2109725,CDM,272,RC,,,outpatient,,,20.37,12.22,,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,18.33,
SUTURE J593G 5-0 CO VIC,2101825,CDM,272,RC,,,outpatient,,,69.49,41.69,,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,62.54,
SUTURE J594G 4-0 CO VIC,2101826,CDM,272,RC,,,outpatient,,,69.49,41.69,,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.24,62.54,
SUTURE J598G,2108539,CDM,272,RC,,,outpatient,,,61.43,36.86,,46.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.59,55.29,
SUTURE J603H*,2108704,CDM,272,RC,,,outpatient,,,18.54,11.12,,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.69,
SUTURE J649G,2110578,CDM,272,RC,,,outpatient,,,146.83,88.1,,110.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.09,132.15,
SUTURE J662H 4-0 CO VIC,2101827,CDM,272,RC,,,outpatient,,,29.71,17.83,,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,26.74,
SUTURE J663H 3-0 CO VIC,2101828,CDM,272,RC,,,outpatient,,,29.71,17.83,,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.09,26.74,
SUTURE J724D,2108669,CDM,272,RC,,,outpatient,,,189.68,113.81,,142.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,142.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,119.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.87,170.71,
SUTURE J726D,2112570,CDM,272,RC,,,outpatient,,,207.34,124.4,,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,130.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.48,186.61,
SUTURE J727D 0 CO VIC,2101829,CDM,272,RC,,,outpatient,,,76.92,46.15,,57.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.76,69.23,
SUTURE J740D O VICRYL*,2101906,CDM,272,RC,,,outpatient,,,150.79,90.47,,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,135.71,
SUTURE J774D,2112485,CDM,272,RC,,,outpatient,,,226.2,135.72,,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,203.58,
SUTURE J775D,2100377,CDM,272,RC,,,outpatient,,,226.2,135.72,,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,203.58,
SUTURE J784G,2102046,CDM,272,RC,,,outpatient,,,199.23,119.54,,149.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.82,179.31,
SUTURE J784G,2108914,CDM,272,RC,,,outpatient,,,166.04,99.62,,124.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,104.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.02,149.44,
SUTURE J824G,2108538,CDM,272,RC,,,outpatient,,,68,40.8,,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.93,61.2,
SUTURE J833G 6-0 CO VIC,2101830,CDM,272,RC,,,outpatient,,,69.94,41.96,,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.33,62.95,
SUTURE J845G,2109719,CDM,272,RC,,,outpatient,,,44.34,26.6,,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,39.91,
SUTURE J849G,2108485,CDM,272,RC,,,outpatient,,,119.46,71.68,,89.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.48,107.51,
SUTURE J880T,2102600,CDM,272,RC,,,outpatient,,,54.32,32.59,,40.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.13,48.89,
SUTURE J906G,2108982,CDM,272,RC,,,outpatient,,,113.73,68.24,,85.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,71.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.3,102.36,
SUTURE J912G*,2109029,CDM,272,RC,,,outpatient,,,125.39,75.23,,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.69,112.85,
SUTURE J945H*,2102605,CDM,272,RC,,,outpatient,,,35.51,21.31,,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.28,31.96,
SUTURE J946H,2109030,CDM,272,RC,,,outpatient,,,21.22,12.73,,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,19.1,
SUTURE J974G,2109601,CDM,272,RC,,,outpatient,,,184.67,110.8,,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.84,166.2,
SUTURE J978H 0 CO VIC,2101832,CDM,272,RC,,,outpatient,,,34.27,20.56,,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.02,30.84,
SUTURE JB839,2112552,CDM,272,RC,,,outpatient,,,63.93,38.36,,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,57.54,
SUTURE JJ31G,2108971,CDM,272,RC,,,outpatient,,,164.98,98.99,,123.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,103.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.8,148.48,
SUTURE K570H,2109023,CDM,272,RC,,,outpatient,,,48.28,28.97,,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,43.45,
SUTURE K571H,2109022,CDM,272,RC,,,outpatient,,,45.94,27.56,,34.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.41,41.35,
SUTURE K832H 3-0 SILK,2101833,CDM,272,RC,,,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,25.82,
SUTURE K833H 2-0 SILK,2101834,CDM,272,RC,,,outpatient,,,21.31,12.79,,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,19.18,
SUTURE K834H,2101835,CDM,272,RC,,,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,25.82,
SUTURE K842H 3-0 SILK,2102316,CDM,272,RC,,,outpatient,,,20.69,12.41,,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,18.62,
SUTURE K871H,2101836,CDM,272,RC,,,outpatient,,,9.97,5.98,,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,8.97,
SUTURE K872H,2101837,CDM,272,RC,,,outpatient,,,21.54,12.92,,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,19.39,
SUTURE K881H 4-0 SILK,2101838,CDM,272,RC,,,outpatient,,,17.48,10.49,,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,15.73,
SUTURE L101G 4-0 GUT PL,2101840,CDM,272,RC,,,outpatient,,,24.6,14.76,,18.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.04,22.14,
SUTURE L102G 3-0 GUT PL,2101841,CDM,272,RC,,,outpatient,,,22.13,13.28,,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.53,19.92,
SUTURE L104G,2102602,CDM,272,RC,,,outpatient,,,32.78,19.67,,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.72,29.5,
SUTURE L111G 4-0 GUT CHR,2101842,CDM,272,RC,,,outpatient,,,24.82,14.89,,18.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,22.34,
SUTURE L112G 3-0 GUT CHR,2101843,CDM,272,RC,,,outpatient,,,36.62,21.97,,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,32.96,
SUTURE L113G 2-0 GUT CHR,2101844,CDM,272,RC,,,outpatient,,,36.62,21.97,,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.5,32.96,
SUTURE L114G 0 GUT CHR,2101845,CDM,272,RC,,,outpatient,,,33.53,20.12,,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.87,30.18,
SUTURE L886T,2103140,CDM,272,RC,,,outpatient,,,56.97,34.18,,42.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.67,51.27,
SUTURE M154T 4-0 SILK,2101846,CDM,272,RC,,,outpatient,,,121.29,72.77,,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,109.16,
SUTURE PDP880G,2112251,CDM,272,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
SUTURE R832H 3-0 MER,2101922,CDM,272,RC,,,outpatient,,,17.21,10.33,,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.53,15.49,
SUTURE R833H 2-0 MER,2101946,CDM,272,RC,,,outpatient,,,15.7,9.42,,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,14.13,
SUTURE R834H 0 MERS,2101848,CDM,272,RC,,,outpatient,,,31.61,18.97,,23.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.48,28.45,
SUTURE REMOVAL KIT,2100225,CDM,272,RC,,,outpatient,,,16.48,9.89,,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,14.83,
SUTURE RESTERILIZED,2102972,CDM,272,RC,,,outpatient,,,14.43,8.66,,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,12.99,
SUTURE RS22,2109952,CDM,272,RC,,,outpatient,,,101.35,60.81,,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,63.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.77,91.22,
SUTURE RS23,2108922,CDM,272,RC,,,outpatient,,,103.01,61.81,,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,92.71,
SUTURE RSB5 RETENTION BRIDGE,2100275,CDM,272,RC,,,outpatient,,,92.06,55.24,,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.86,82.85,
SUTURE SA63H 4-0 SILK,2101911,CDM,272,RC,,,outpatient,,,17.19,10.31,,12.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.52,15.47,
SUTURE SA66G 0 SILK,2101849,CDM,272,RC,,,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,23.12,
SUTURE SA83H 4-0 SILK,2101850,CDM,272,RC,,,outpatient,,,17.29,10.37,,12.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,15.56,
SUTURE SA84H 3-0 SILK,2101931,CDM,272,RC,,,outpatient,,,21.12,12.67,,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.33,19.01,
SUTURE SA85H,2109344,CDM,272,RC,,,outpatient,,,28.33,17,,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,25.5,
SUTURE SA86G 0-SILK,2102688,CDM,272,RC,,,outpatient,,,24.08,14.45,,18.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,21.67,
SUTURE SN689*,2111539,CDM,272,RC,,,outpatient,,,26.98,16.19,,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,24.28,
SUTURE SR66G,2102632,CDM,272,RC,,,outpatient,,,26.74,16.04,,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.48,24.07,
SUTURE TI-CRON 3027-79*,2110608,CDM,272,RC,,,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,13.91,
SUTURE TI-CRON 5 3127-79,2110607,CDM,272,RC,,,outpatient,,,229.15,137.49,,171.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,144.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.95,206.24,
SUTURE U10T UMB TAPE,2101857,CDM,272,RC,,,outpatient,,,17.76,10.66,,13.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,15.98,
SUTURE U12T,2102928,CDM,272,RC,,,outpatient,,,33.33,20,,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,30,
SUTURE U202H,2108315,CDM,272,RC,,,outpatient,,,27.9,16.74,,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.72,25.11,
SUTURE U203H 4-0 GUT CHR,2101853,CDM,272,RC,,,outpatient,,,17.08,10.25,,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,15.37,
SUTURE V448G 10-0 VICRYL MONOFILAMENT,2109167,CDM,272,RC,,,outpatient,,,294.77,176.86,,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,185.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.4,265.29,
SUTURE V950G 9-0 VICRYL,2109168,CDM,272,RC,,,outpatient,,,181.2,108.72,,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.13,163.08,
SUTURE V966G 10-0 VICRYL MONOFILAMENT,2109166,CDM,272,RC,,,outpatient,,,189.59,113.75,,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,119.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.85,170.63,
SUTURE VCP495H,2112135,CDM,272,RC,,,outpatient,,,150.79,90.47,,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.9,135.71,
SUTURE VCPP31D,2109296,CDM,272,RC,,,outpatient,,,138.02,82.81,,103.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.28,124.22,
SUTURE VICRYL 3.0 VCP427H,2111622,CDM,272,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
SUTURE VICRYL 4.0 VCP426H,2111620,CDM,272,RC,,,outpatient,,,17.61,10.57,,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,15.85,
SUTURE VICRYL 5.0 VCP495H,2111621,CDM,272,RC,,,outpatient,,,17.61,10.57,,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,15.85,
SUTURE X412H,2112315,CDM,272,RC,,,outpatient,,,8.74,5.24,,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.79,7.87,
SUTURE X424H ETHIBOND,2111314,CDM,272,RC,,,outpatient,,,11.21,6.73,,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,10.09,
SUTURE X548H,2111540,CDM,272,RC,,,outpatient,,,34.91,20.95,,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,31.42,
SUTURE X844H,2102353,CDM,272,RC,,,outpatient,,,72.36,43.42,,54.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,65.12,
SUTURE X844H 0 MER,2101945,CDM,272,RC,,,outpatient,,,24.85,14.91,,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,22.37,
SUTURE Y274H,2102843,CDM,272,RC,,,outpatient,,,28.43,17.06,,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,25.59,
SUTURE Y333H,2102844,CDM,272,RC,,,outpatient,,,28.43,17.06,,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.83,25.59,
SUTURE Y416H,2108488,CDM,272,RC,,,outpatient,,,31.3,18.78,,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.41,28.17,
SUTURE Y464G*,2112905,CDM,272,RC,,,outpatient,,,102.44,61.46,,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.99,92.2,
SUTURE Y495G,2108478,CDM,272,RC,,,outpatient,,,69.28,41.57,,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,62.35,
SUTURE Y496G,2108480,CDM,272,RC,,,outpatient,,,69.28,41.57,,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.2,62.35,
SUTURE Y513GG,2112887,CDM,272,RC,,,outpatient,,,70.48,42.29,,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.44,63.43,
SUTURE Y606H,2109032,CDM,272,RC,,,outpatient,,,33.31,19.99,,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.83,29.98,
SUTURE Y834G,2108483,CDM,272,RC,,,outpatient,,,76.17,45.7,,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,47.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.61,68.55,
SUTURE Y844G,2111464,CDM,272,RC,,,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.88,25.82,
SUTURE Y845G 4-0 PDS,2112462,CDM,272,RC,,,outpatient,,,84.95,50.97,,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,76.46,
SUTURE Y917H,2103096,CDM,272,RC,,,outpatient,,,56.01,33.61,,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,50.41,
SUTURE Y918H,2103095,CDM,272,RC,,,outpatient,,,56.01,33.61,,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.48,50.41,
SUTURE Y935H,2108542,CDM,272,RC,,,outpatient,,,68.86,41.32,,51.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.11,61.97,
SUTURE Z304H,2112642,CDM,272,RC,,,outpatient,,,11.21,6.73,,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.3,10.09,
SUTURE Z315H,2108587,CDM,272,RC,,,outpatient,,,40.43,24.26,,30.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,36.39,
SUTURE Z316H,2102872,CDM,272,RC,,,outpatient,,,42.62,25.57,,31.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,38.36,
SUTURE Z340H MONO 27,2111676,CDM,272,RC,,,outpatient,,,9.87,5.92,,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.02,8.88,
SUTURE Z347H,2109217,CDM,272,RC,,,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,31.73,
SUTURE Z371T,2101505,CDM,272,RC,,,outpatient,,,45.07,27.04,,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.23,40.56,
SUTURE Z467H 0 PDS VIL MONO,2101855,CDM,272,RC,,,outpatient,,,25.04,15.02,,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.13,22.54,
SUTURE Z740D,2111576,CDM,272,RC,,,outpatient,,,82.5,49.5,,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.9,74.25,
SUTURE Z774D,2111788,CDM,272,RC,,,outpatient,,,79.23,47.54,,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,71.31,
SUTURE Z844G,2102873,CDM,272,RC,,,outpatient,,,84.95,50.97,,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,76.46,
SUTURE Z845G,2111442,CDM,272,RC,,,outpatient,,,84.95,50.97,,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.41,76.46,
SWANZ GANZ CATH VIP 7.5F,2100585,CDM,272,RC,,,outpatient,,,339.91,203.95,,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,214.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.65,305.92,
SWANZ GANZ PACE PORT CATH 7.5F,2102380,CDM,272,RC,,,outpatient,,,419.07,251.44,,314.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,264.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.87,377.16,
SYNTHES 2.5 DRILL BIT 310.25,2111499,CDM,272,RC,,,outpatient,,,346.39,207.83,,259.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,259.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,218.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.98,311.75,
SYNTHES SAW BLADE,2109838,CDM,272,RC,,,outpatient,,,144.82,86.89,,108.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,91.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,130.34,
SYNTHES SAW BLADE 05.002.003S,2111215,CDM,272,RC,,,outpatient,,,158.17,94.9,,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,99.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.41,142.35,
SYNTHES SAW BLADE 519.116S/519.117S,2111110,CDM,272,RC,,,outpatient,,,142.9,85.74,,107.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.28,128.61,
SYRINGE MEDALLION 10CC MSS111-R,2109519,CDM,272,RC,,,outpatient,,,25.68,15.41,,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,23.11,
SYRINGE MEDALLION 3CC MSS031-R,2109518,CDM,272,RC,,,outpatient,,,25.68,15.41,,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,23.11,
SYSTEM ONE LAP CBDE KIT 50000,2109092,CDM,272,RC,,,outpatient,,,1092.3,655.38,,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,983.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,688.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.81,983.07,
T CUFF STERILE 5311-15-000,2109756,CDM,272,RC,,,outpatient,,,239.58,143.75,,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,150.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,215.62,
T TUBES 10FR,2100077,CDM,272,RC,,,outpatient,,,73.1,43.86,,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.98,65.79,
T TUBES 12FR,2100076,CDM,272,RC,,,outpatient,,,95.58,57.35,,71.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.58,86.02,
T TUBES 14FR,2100075,CDM,272,RC,,,outpatient,,,101.21,60.73,,75.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,63.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.74,91.09,
T TUBES 16FR,2100074,CDM,272,RC,,,outpatient,,,48.28,28.97,,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,43.45,
TEGADERM 2 3/8X2 3/4,2100632,CDM,272,RC,,,outpatient,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.17,
TEGADERM 3 1/2X4 1/2*,2111864,CDM,272,RC,,,outpatient,,,5.19,3.11,,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.06,4.67,
TEGADERM 8X12,2103780,CDM,272,RC,,,outpatient,,,38.61,23.17,,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,34.75,
TEGADERM DRESSING 4X4 3/4 450901626W,2109437,CDM,272,RC,,,outpatient,,,5.84,3.5,,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,5.26,
TEGADERM FOAM 90614,2111865,CDM,272,RC,,,outpatient,,,14.85,8.91,,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.04,13.37,
TEGADERM XLG 4509001650,2111880,CDM,272,RC,,,outpatient,,,5.2,3.12,,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,4.68,
TELFA PADS 2X3,2111559,CDM,272,RC,,,outpatient,,,4.35,2.61,,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,3.92,
TELFA PADS 3X4*,2100017,CDM,272,RC,,,outpatient,,,3.09,1.85,,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.63,2.78,
THERMA CHOICE CATH TC013,2109187,CDM,272,RC,,,outpatient,,,1511.57,906.94,,1133.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1209.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,321.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1133.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1360.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1133.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1133.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1133.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1133.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,952.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.72,1360.41,
TIPSTOP DRESSING TIPSTOP,2109503,CDM,272,RC,,,outpatient,,,9.23,5.54,,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.89,8.31,
TOWEL DISP 7550,2101512,CDM,272,RC,,,outpatient,,,3.55,2.13,,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,3.2,
TRAC INN CANN 6.0,2101191,CDM,272,RC,,,outpatient,,,302.46,181.48,,226.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,190.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.97,272.21,
TRAC SHILEY 10 INNER CANNULA,2108824,CDM,272,RC,,,outpatient,,,34.91,20.95,,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.15,31.42,
TRAC SHILEY 4 4DCFS,2111031,CDM,272,RC,,,outpatient,,,225.37,135.22,,169.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.18,202.83,
TRAC SHILEY 4 INNER CANNULA 4DIC,2111032,CDM,272,RC,,,outpatient,,,21.03,12.62,,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,18.93,
TRAC SHILEY 8 INNER CANNULA 8DIC,2101443,CDM,272,RC,,,outpatient,,,44.81,26.89,,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.18,40.33,
TRAC SHILEY CUFFED #4 4DCT,2111468,CDM,272,RC,,,outpatient,,,251.6,150.96,,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,226.44,
TRAC SHILEY CUFFED #6 6DCT,2111467,CDM,272,RC,,,outpatient,,,251.6,150.96,,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.55,226.44,
TRAC SHILEY CUFFED #8 8DCT*,2102925,CDM,272,RC,,,outpatient,,,596.35,357.81,,447.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,447.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,536.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,447.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,375.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.19,536.72,
TRAC TUBE POR 10.0 SINGLE CUFF,2101568,CDM,272,RC,,,outpatient,,,274.13,164.48,,205.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,172.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.17,246.72,
TRAC TUBE POR 6.0 SINGLE CUFF,2100602,CDM,272,RC,,,outpatient,,,261.08,156.65,,195.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,195.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,164.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.5,234.97,
TRAC TUBE POR 7.0 SINGLE CUFF,2101535,CDM,272,RC,,,outpatient,,,310.06,186.04,,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,279.05,
TRAC TUBE POR 8.0 SINGLE CUFF,2101534,CDM,272,RC,,,outpatient,,,251.33,150.8,,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.5,226.2,
TRAC TUBE POR 9.0 SINGLE CUFF,2101533,CDM,272,RC,,,outpatient,,,1989.29,1193.57,,1491.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1591.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1491.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1790.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1491.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1491.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1491.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1491.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1253.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.61,1790.36,
TRAC TUBE SHILEY 4.0 DCFN,2109109,CDM,272,RC,,,outpatient,,,312.22,187.33,,234.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,234.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,234.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.97,281,
TRAC TUBE SHILEY 4.0 DCT,2109110,CDM,272,RC,,,outpatient,,,329.52,197.71,,247.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,247.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,247.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,207.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.52,296.57,
TRAC TUBE SHILEY 4.0 DFEN,2109108,CDM,272,RC,,,outpatient,,,344.79,206.87,,258.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,217.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.65,310.31,
TRAC TUBE SHILEY 5.0 SCT,2109111,CDM,272,RC,,,outpatient,,,238.06,142.84,,178.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,149.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.78,214.25,
TRACH SPONGE,2100551,CDM,272,RC,,,outpatient,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,5.17,
TRACH TUBE #6 INNER CANNULA 6DIC,2103159,CDM,272,RC,,,outpatient,,,49.17,29.5,,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.07,44.25,
TRACH TUBE PORTEX 4.0MM,2103065,CDM,272,RC,,,outpatient,,,428.28,256.97,,321.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,321.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,385.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,321.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,269.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.75,385.45,
TRACH TUBE SHILEY 5.5 PED,2101442,CDM,272,RC,,,outpatient,,,494.16,296.5,,370.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,444.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,370.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,311.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.25,444.74,
TRACH TUBE SHILEY CUFFED #10,2102924,CDM,272,RC,,,outpatient,,,545.62,327.37,,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,343.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.8,491.06,
TRACH TUBE SHILEY CUFFED #7,2102923,CDM,272,RC,,,outpatient,,,545.62,327.37,,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,343.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.8,491.06,
TRACH TUBE SHILEY FED 8.0 UNCUFFED,2102916,CDM,272,RC,,,outpatient,,,516.56,309.94,,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,325.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.84,464.9,
TRACH TUBE SHILEY FEN 8.0 CUFFED,2102915,CDM,272,RC,,,outpatient,,,571.51,342.91,,428.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,428.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,514.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,428.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,360.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.1,514.36,
TRACH TUBE SHILEY PED #4,2101718,CDM,272,RC,,,outpatient,,,421.71,253.03,,316.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,316.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.41,379.54,
TRACH TUBE SHILEY PED #6,2102398,CDM,272,RC,,,outpatient,,,413.23,247.94,,309.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,309.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,371.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,309.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,260.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.67,371.91,
TRACH TUBE SHILEY TRAC 7.0 7SCT,2108977,CDM,272,RC,,,outpatient,,,279.02,167.41,,209.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,209.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,251.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,209.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,175.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.17,251.12,
TRANSDUCER EDWARDS,2102208,CDM,272,RC,,,outpatient,,,274.28,164.57,,205.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,172.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.2,246.85,
TRAV BLOOD SET ANES,2111822,CDM,272,RC,,,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.1,26.8,
TRAV SECONDARY SET,2102560,CDM,272,RC,,,outpatient,,,16.48,9.89,,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,14.83,
TRAY 16F W/URIMETER,2103801,CDM,272,RC,,,outpatient,,,159,95.4,,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.58,143.1,
TRAY 18F W/URIMETER,2103802,CDM,272,RC,,,outpatient,,,161.18,96.71,,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,145.06,
TRAY AMNIOCENTESIS,2100528,CDM,272,RC,,,outpatient,,,152.16,91.3,,114.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.18,136.94,
TRAY ARTHROGRAM 4325S,2110754,CDM,272,RC,,,outpatient,,,126.57,75.94,,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.93,113.91,
TRAY CUTDOWN DISP,2102941,CDM,272,RC,,,outpatient,,,324.54,194.72,,243.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,243.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,243.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.5,292.09,
TRAY DOUBLE BASIN PLUS DYNJ06804,2108965,CDM,272,RC,,,outpatient,,,178.23,106.94,,133.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,112.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.52,160.41,
TRAY EPIDURAL CONTINUOUS*,2108381,CDM,272,RC,,,outpatient,,,433.82,260.29,,325.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,325.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,325.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,273.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.89,390.44,
TRAY EPIDURAL/SPINAL,2108736,CDM,272,RC,,,outpatient,,,336.09,201.65,,252.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,252.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,252.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.86,302.48,
TRAY FOLEY 16FR*,2100083,CDM,272,RC,,,outpatient,,,31.93,19.16,,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,28.74,
TRAY FOLEY 18FR*,2100084,CDM,272,RC,,,outpatient,,,79.23,47.54,,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,71.31,
TRAY HICKMAN DRESSING,2100642,CDM,272,RC,,,outpatient,,,28.84,17.3,,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.91,25.96,
TRAY IRRIGATION,2100163,CDM,272,RC,,,outpatient,,,21.86,13.12,,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.48,19.67,
TRAY LACERATION DISP,2102549,CDM,272,RC,,,outpatient,,,310.03,186.02,,232.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,279.03,
TRAY LUMB PUNC ADULT,2100159,CDM,272,RC,,,outpatient,,,248.32,148.99,,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,223.49,
TRAY LUMB PUNC PED,2100160,CDM,272,RC,,,outpatient,,,255.7,153.42,,191.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,161.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.39,230.13,
TRAY PARACENTHESIS KIT TPK1001,2108729,CDM,272,RC,,,outpatient,,,219.1,131.46,,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.89,197.19,
TRAY PARACENTHESIS TPT1000,2108728,CDM,272,RC,,,outpatient,,,147.79,88.67,,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,133.01,
TRAY PARACERVICAL/PUDENDAL,2108769,CDM,272,RC,,,outpatient,,,89.33,53.6,,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.3,80.4,
TRAY PERM CATH 45CM,2108604,CDM,272,RC,,,outpatient,,,562.28,337.37,,421.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,421.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,354.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.21,506.05,
TRAY PICC LINE ADULT,2103413,CDM,272,RC,C1751,HCPCS,outpatient,,,432.74,259.64,,324.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,324.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,389.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,324.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,272.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.67,389.47,
TRAY PREP EXIDINE,2103441,CDM,272,RC,,,outpatient,,,174.83,104.9,,131.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,110.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.82,157.35,
TRAY SHAVE PREP,2100176,CDM,272,RC,,,outpatient,,,45.9,27.54,,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,41.31,
TRAY SPINAL S25BK*,2102877,CDM,272,RC,,,outpatient,,,206.53,123.92,,154.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,130.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.32,185.88,
TRAY SUCTION POLYP 00711099,2109358,CDM,272,RC,,,outpatient,,,101.62,60.97,,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,91.46,
TRAY SUTURE PLASTIC,2100452,CDM,272,RC,,,outpatient,,,118.08,70.85,,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.19,106.27,
TRAY THORACENTESIS,2100158,CDM,272,RC,,,outpatient,,,206.8,124.08,,155.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,155.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,130.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.37,186.12,
TRAY TRACHEOSTOMY,2100085,CDM,272,RC,,,outpatient,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,10.82,
TRAY URETHRAL CLOSED DYND10407,2101259,CDM,272,RC,,,outpatient,,,156.54,93.92,,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,98.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.08,140.89,
TRAY URETHRAL*,2100078,CDM,272,RC,,,outpatient,,,20.6,12.36,,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.22,18.54,
TRAY WET SKIN PREP MEDLINE,2102871,CDM,272,RC,,,outpatient,,,55.59,33.35,,41.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.39,50.03,
TRISTATE ANCHORS ANC32XT,2109540,CDM,272,RC,,,outpatient,,,29.28,17.57,,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6,26.35,
TRISTATE DRESSING 6X8 STAD68,2102644,CDM,272,RC,,,outpatient,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.02,13.28,
TRISTATE ISLAND DRESSING 2 in 2X2 STAD22,2102641,CDM,272,RC,,,outpatient,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.4,6.15,
TRISTATE ISLAND DRESSING 4 in 4X4 STAD44,2109360,CDM,272,RC,,,outpatient,,,19.57,11.74,,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,17.61,
TRISTATE NUBE NEEDLE,2103813,CDM,272,RC,,,outpatient,,,102.38,61.43,,76.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.98,92.14,
TRISTATE SORBRAVIEW DRESS 3 inch,2103444,CDM,272,RC,,,outpatient,,,24.04,14.42,,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,21.64,
TRISTATE SORBRAVIEW DRESS 4 1/2,2103445,CDM,272,RC,,,outpatient,,,15.3,9.18,,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,13.77,
TRISTATE SORBRAVIEW DRESS 5/8,2103446,CDM,272,RC,,,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
TRISTATE TRAY DROP ON INCISION,2108463,CDM,272,RC,,,outpatient,,,46.58,27.95,,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.54,41.92,
TROCAR 10MM SHORT,2108403,CDM,272,RC,,,outpatient,,,358.26,214.96,,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,225.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.41,322.43,
TROCAR CATH 10FR,2101987,CDM,272,RC,,,outpatient,,,146.42,87.85,,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30,131.78,
TROCAR CATH 8FR,2101986,CDM,272,RC,,,outpatient,,,162.81,97.69,,122.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.36,146.53,
TROCAR KIT 12F,2101327,CDM,272,RC,,,outpatient,,,404.42,242.65,,303.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,323.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,303.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,254.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.87,363.98,
TROCAR KIT 20F,2100506,CDM,272,RC,,,outpatient,,,420.97,252.58,,315.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,336.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,315.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,315.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.26,378.87,
TROCAR KIT 28F,2101444,CDM,272,RC,,,outpatient,,,317.53,190.52,,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,200.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.06,285.78,
TUBES MICRON PLUS VENTALATION,2103356,CDM,272,RC,,,outpatient,,,493.09,295.85,,369.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,369.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,369.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,310.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.03,443.78,
TUBES REUTER BOBBIN VENTILATION,2103357,CDM,272,RC,,,outpatient,,,101.53,60.92,,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,63.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.8,91.38,
UMB CATH 3.5FR,2100507,CDM,272,RC,,,outpatient,,,63.93,38.36,,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,57.54,
UMB CATH 5FR,2100508,CDM,272,RC,,,outpatient,,,116.65,69.99,,87.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.9,104.99,
UMB CATH 8FR,2101578,CDM,272,RC,,,outpatient,,,63.93,38.36,,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,57.54,
UMBILICAL TAPE,2100430,CDM,272,RC,,,outpatient,,,10.65,6.39,,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,9.59,
UNNA BOOT GELOCAST*,2108433,CDM,272,RC,,,outpatient,,,131.68,79.01,,98.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.98,118.51,
URIMETER 16F MEDLINE,2109253,CDM,272,RC,,,outpatient,,,96.44,57.86,,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,86.8,
URINE METER,2100191,CDM,272,RC,,,outpatient,,,84.42,50.65,,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.3,75.98,
UTERINE CURETTE STR. 10MM,2102624,CDM,272,RC,,,outpatient,,,53.47,32.08,,40.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.96,48.12,
UTERINE CURETTE SWIVAL HANDLE & TUBING,2102622,CDM,272,RC,,,outpatient,,,95.07,57.04,,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.48,85.56,
UTERINE EXPLORA CURETTE 3MM,2108773,CDM,272,RC,,,outpatient,,,59.01,35.41,,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,53.11,
UTERINE EXPLORA CURETTE 4MM,2108774,CDM,272,RC,,,outpatient,,,59.01,35.41,,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.09,53.11,
UTERINE MANIPULATOR UM-4.5,2102364,CDM,272,RC,,,outpatient,,,293.66,176.2,,220.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,220.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,185.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.17,264.29,
V LOC 180 0 WOUND CLOSURE DEVICE,2111786,CDM,272,RC,,,outpatient,,,179.93,107.96,,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,161.94,
V LOC 180 2-0 WOUND CLOSURE DEVICE,2111785,CDM,272,RC,,,outpatient,,,179.93,107.96,,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,161.94,
V LOC 180 2-0 WOUND CLOSURE DEVICE,2111795,CDM,272,RC,,,outpatient,,,179.93,107.96,,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,161.94,
V LOC 180 3-0 WOUND CLOSURE DEVICE,2111784,CDM,272,RC,,,outpatient,,,160.62,96.37,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,144.56,
V LOC 180 3-0 WOUND CLOSURE DEVICE,2111794,CDM,272,RC,,,outpatient,,,160.62,96.37,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,144.56,
V LOC 90 2-0 WOUND CLOSURE DEVICE,2111790,CDM,272,RC,,,outpatient,,,160.62,96.37,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,144.56,
V LOC 90 WOU CLOS DEV VLOCM0035,2111797,CDM,272,RC,,,outpatient,,,212.08,127.25,,159.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,159.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,133.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.46,190.87,
V LOC 90 WOU CLOS DEV VLOCM0135,2111798,CDM,272,RC,,,outpatient,,,179.93,107.96,,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.87,161.94,
VALLEY LAB TRIGGER SWITCH AND CORD,2112299,CDM,272,RC,,,outpatient,,,76.77,46.06,,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.73,69.09,
VARI-STIM III,2101740,CDM,272,RC,,,outpatient,,,282.84,169.7,,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,178.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.95,254.56,
VAS-CATH JUG KIT 5524200,2102190,CDM,272,RC,,,outpatient,,,907.49,544.49,,680.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,725.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,193.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,680.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,816.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,680.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,571.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.94,816.74,
VAS-CATH JUGULAR PC CXK 3600PC(5524150),2103116,CDM,272,RC,,,outpatient,,,890.2,534.12,,667.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,712.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,667.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,801.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,667.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,560.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.4,801.18,
VAS-CATH SUB CLAV CXK-4000 (5523150),2102230,CDM,272,RC,,,outpatient,,,881.29,528.77,,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,793.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,555.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.58,793.16,
VAS-CATH SUB FEM JUG CXK4400 (5523200),2102327,CDM,272,RC,,,outpatient,,,881.29,528.77,,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,793.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,555.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.58,793.16,
VASCULAR ACCESS TUNNELER LG ORANGE 9009-,2109655,CDM,272,RC,,,outpatient,,,208.04,124.82,,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,131.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,187.24,
VASCULAR BOOTIE VB-1115,2108624,CDM,272,RC,,,outpatient,,,18.57,11.14,,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.71,
VASCULAR SHEATH 6MM 12 9009-22,2109657,CDM,272,RC,,,outpatient,,,208.04,124.82,,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,131.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,187.24,
VASCULAR SHEATH 6MM 9009-23,2109658,CDM,272,RC,,,outpatient,,,208.04,124.82,,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,131.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,187.24,
VASCULAR TUNNELER SM GREEN 9009-18,2109654,CDM,272,RC,,,outpatient,,,208.04,124.82,,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,131.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.63,187.24,
VASCUTECH EXPANDABLE LEMAITRE VALVULOTOM,2103269,CDM,272,RC,,,outpatient,,,1056.76,634.06,,792.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,792.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,951.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,792.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,792.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,665.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.53,951.08,
VASELINE GAUZE 1X8,2102142,CDM,272,RC,,,outpatient,,,2.06,1.24,,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.42,1.85,
VASELINE GAUZE 3/9,2100009,CDM,272,RC,,,outpatient,,,10.65,6.39,,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.18,9.59,
VASELINE GAUZE 6/36,2100011,CDM,272,RC,,,outpatient,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,11.32,
VENI-GARD DRESSING,2108389,CDM,272,RC,,,outpatient,,,5.84,3.5,,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.2,5.26,
VENOCATH 18,2101693,CDM,272,RC,,,outpatient,,,29.23,17.54,,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.99,26.31,
VENT CIRCUIT LP599-010,2109532,CDM,272,RC,,,outpatient,,,43.82,26.29,,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,39.44,
VERSABOND 71271340,2109895,CDM,272,RC,,,outpatient,,,286.57,171.94,,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,180.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.72,257.91,
VISITEC FLUID COLLECTION BAG W/WECK10CC,2108767,CDM,272,RC,,,outpatient,,,22.81,13.69,,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.67,20.53,
WEDGE 23X11X11,2111697,CDM,272,RC,,,outpatient,,,11.33,6.8,,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.32,10.2,
WRIGHT,2111275,CDM,272,RC,,,outpatient,,,636.12,381.67,,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,572.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,400.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.34,572.51,
WRIGHT DRILL BIT 2694-9464,2110885,CDM,272,RC,,,outpatient,,,308.94,185.36,,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,194.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.3,278.05,
WRIGHT DRILL BIT2.0 2694-9461,2111388,CDM,272,RC,,,outpatient,,,308.94,185.36,,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,194.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.3,278.05,
WRIGHT DRILL KIT PINDRLBT,2110498,CDM,272,RC,,,outpatient,,,353.06,211.84,,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,222.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,317.75,
WRIGHT G-WIRE 0103-600,2111270,CDM,272,RC,,,outpatient,,,410.99,246.59,,308.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,308.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,308.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,258.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.21,369.89,
WRIGHT K WIRE 5941-0625,2109879,CDM,272,RC,,,outpatient,,,147.15,88.29,,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,132.44,
WRIGHT PIN PK K000-1296,2110505,CDM,272,RC,,,outpatient,,,264.8,158.88,,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,238.32,
WRIGHT SAW BLADE T20310,2110504,CDM,272,RC,,,outpatient,,,342.03,205.22,,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,307.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,215.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.08,307.83,
XEROFORM 1X8*,2102455,CDM,272,RC,,,outpatient,,,12.36,7.42,,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.53,11.12,
XEROFORM 5X9,2102424,CDM,272,RC,,,outpatient,,,13.79,8.27,,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.83,12.41,
ZIM FEMORAL BRUSH TIP 00515018300,2109916,CDM,272,RC,,,outpatient,,,101.63,60.98,,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,91.47,
ZIM PULSAVAC PLUS 5150-475,2109915,CDM,272,RC,,,outpatient,,,46.35,27.81,,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.5,41.72,
ZIMMER DISP CUFF 18,2108600,CDM,272,RC,,,outpatient,,,239.58,143.75,,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,150.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.09,215.62,
ZIMMER FAN SPRAY TIP 5150-175,2110616,CDM,272,RC,,,outpatient,,,92.83,55.7,,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.02,83.55,
ZIMMER KNEE TRACTION BOOT 1774-001,2110515,CDM,272,RC,,,outpatient,,,154.35,92.61,,115.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.63,138.92,
ZIMMER SKIN GRAFT CARRIER 16'',2103053,CDM,272,RC,,,outpatient,,,218.23,130.94,,163.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,163.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,137.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.72,196.41,
ZIMMER SKIN GRAFT CARRIER 8,2103054,CDM,272,RC,,,outpatient,,,167.47,100.48,,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.31,150.72,
ADR REHAB KNEE SLIDER 16-28 1291-4VC-28,2109933,CDM,274,RC,L1832,HCPCS,both,,,1987.7,1192.62,,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1292.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,427.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1590.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1252.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.28,1590.16,
ARD REHAB KNEE SLIDER 16-22 1291-4VC,2109932,CDM,274,RC,L1832,HCPCS,both,,,1987.7,1192.62,,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1590.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1292.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,427.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1590.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1490.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1252.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.28,1590.16,
COLLAR CERVICAL EXTR ADJ.*,2113087,CDM,274,RC,,,both,,,43.05,25.83,,32.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,9.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,32.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.82,34.44,
COLLAR SOFT UNIVERSAL 79-83510,2110528,CDM,274,RC,,,both,,,37.71,22.63,,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,8.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.73,30.17,
"GRADIENT COMPRESSION,LYMPHEDEMA",2800078,CDM,274,RC,L8220,HCPCS,both,,,484.63,290.78,,363.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,315.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,104.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,363.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,305.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.3,387.7,
HOLLISTER BARRIER SYSTEM,2102971,CDM,274,RC,A4378,HCPCS,both,,,377.8,226.68,,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,81.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,302.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,238.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.41,302.24,
OSTOMY HOLLISTER BAG 8460,2111087,CDM,274,RC,A4416,HCPCS,both,,,43.71,26.23,,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,9.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.97,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.96,34.97,
PASSY MIUR TRACH SPEAKING VALVE PMV005,2110832,CDM,274,RC,L8501,HCPCS,both,,,415.51,249.31,,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,270.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,89.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,261.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,332.41,
PASSY MIUR TRACH SPEAKING VALVE PMV2001,2111351,CDM,274,RC,L8501,HCPCS,both,,,415.51,249.31,,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,270.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,89.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,332.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,261.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,332.41,
ROYCE ANKLE BRACE LEFT,2103019,CDM,274,RC,L4350,HCPCS,both,,,357.31,214.39,,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,76.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,225.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,285.85,
ROYCE ANKLE BRACE RIGHT E5050R,2103018,CDM,274,RC,L4350,HCPCS,both,,,357.31,214.39,,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,76.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,225.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,285.85,
ROYCE ANKLE BRACE RIGHT E8020R,2103016,CDM,274,RC,L4350,HCPCS,both,,,357.31,214.39,,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,76.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,225.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.21,285.85,
ROYCE WRIST SPLINT SMALL,2108348,CDM,274,RC,,,both,,,96.64,57.98,,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,20.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,77.31,
ROYCE WRIST SPLINT SMALL,2108349,CDM,274,RC,L3984,HCPCS,both,,,96.64,57.98,,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,20.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,77.31,
ROYCE WRIST SPLINT XLG LEFT,2108355,CDM,274,RC,L3908,HCPCS,both,,,143.12,85.87,,107.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,30.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,107.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.33,114.5,
ROYCE WRIST SPLINT XSM LEFT,2108346,CDM,274,RC,L3984,HCPCS,both,,,96.64,57.98,,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,20.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,77.31,
ROYCE WRIST SPLINT XSMALL,2108347,CDM,274,RC,,,both,,,96.64,57.98,,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,20.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.8,77.31,
SHOULDER IMM MED 79-84165,2111584,CDM,274,RC,,,both,,,26.5,15.9,,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,21.2,
SHOULDER IMM MLG 79-84167,2111585,CDM,274,RC,,,both,,,26.5,15.9,,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,21.2,
SHOULDER IMM SM 79-84163,2111583,CDM,274,RC,,,both,,,26.5,15.9,,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,21.2,
SHOULDER IMM X-LG 79-84168,2111586,CDM,274,RC,,,both,,,26.5,15.9,,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,21.2,
STR ORT DRILL 0227-8240S,2111616,CDM,274,RC,,,both,,,724.48,434.69,,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,579.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,470.91,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,155.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,579.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,456.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.45,579.58,
WRIST EXTERNAL FIXATOR,2109902,CDM,274,RC,L3982,HCPCS,both,,,3248.26,1948.96,,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2598.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,691.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2111.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,698.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2598.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2436.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2046.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,665.57,2598.61,
WRIST EXTERNAL FIXATOR STABELOC,2112387,CDM,274,RC,L3982,HCPCS,both,,,4638.47,2783.08,,3478.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3710.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,987.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,987.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3015.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,997.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3710.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3478.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3478.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3478.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3478.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,950.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2922.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,950.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,950.42,3710.78,
WRIST EXTERNAL FIXATOR SYNTHES,2112394,CDM,274,RC,L3982,HCPCS,both,,,2934.77,1760.86,,2201.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2347.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,625.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,625.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1907.6,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,630.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2347.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2201.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2201.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2201.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2201.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,601.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1848.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,601.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,601.33,2347.82,
PACEMAKER DUAL CHAMBER SENSIA,2100476,CDM,275,RC,,,both,,,8385.46,5031.28,,6289.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,6289.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1786.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1786.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5450.55,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1802.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6708.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,6289.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6289.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6289.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6289.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1718.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5282.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1718.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1718.18,6708.37,
PACEMAKER SINGLE CHAMBER SENSIA,2102104,CDM,275,RC,,,both,,,6620.12,3972.07,,4965.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4965.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1410.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1410.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4303.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1423.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5296.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4965.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4965.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4965.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4965.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4170.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.46,5296.1,
ALCON ACRYSOF PANOPTIC LENS TFNT00,2113059,CDM,276,RC,C1780,HCPCS,both,,,1912.28,1147.37,,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1529.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,407.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1242.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,411.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1721.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1204.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,1721.05,
ALCON ACRYSOF PANOPTIC TORIC TFNT30,2113060,CDM,276,RC,C1780,HCPCS,both,,,1912.28,1147.37,,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1529.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,407.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1242.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,411.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1721.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1204.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,1721.05,
ALCON INTRAOCULAR LENS AU00T0,2112838,CDM,276,RC,C1780,HCPCS,both,,,647.17,388.3,,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,139.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,582.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,407.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,582.45,
ALCON INTRAOCULAR LENS MN60AC,2112476,CDM,276,RC,C1780,HCPCS,both,,,884.89,530.93,,663.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,575.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,190.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,796.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,663.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,557.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.31,796.4,
ALCON INTRAOCULAR LENS MTA4UO,2112477,CDM,276,RC,C1780,HCPCS,both,,,208.99,125.39,,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,44.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,131.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.82,188.09,
ALCON INTRAOCULAR LENS SA60AT,2112818,CDM,276,RC,C1780,HCPCS,both,,,647.17,388.3,,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,139.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,582.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,407.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,582.45,
ALCON INTRAOCULAR LENS SN60AT,2112513,CDM,276,RC,C1780,HCPCS,both,,,647.17,388.3,,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,139.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,582.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,407.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.61,582.45,
ALCON INTRAOCULAR LENS SN60WF,2108820,CDM,276,RC,C1780,HCPCS,both,,,376.98,226.19,,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.04,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,81.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,237.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.24,339.28,
ALCON RESTORE LENS 3 PC MN6AD1,2109694,CDM,276,RC,V2788,HCPCS,both,,,1390.22,834.13,,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,296.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,903.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,298.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1251.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,875.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,1251.2,
ALCON RESTORE LENS SINGLE PIECE SN6AD1,2109634,CDM,276,RC,V2788,HCPCS,both,,,1390.22,834.13,,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,296.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,903.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,298.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1251.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,875.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,1251.2,
ALCON TORIC LENS SN6AT3,2110977,CDM,276,RC,V2787,HCPCS,both,,,725.57,435.34,,544.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,471.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,156,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,653.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,544.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,457.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.67,653.01,
SYMFONY RESTORE LENS ZXR00,2112808,CDM,276,RC,V2788,HCPCS,both,,,1390.22,834.13,,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1112.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,296.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,903.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,298.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1251.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1042.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,875.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,284.86,1251.2,
ADV O S 5.0X85 8021-085,2111356,CDM,278,RC,,,both,,,571.72,343.03,,428.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,428.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,371.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,122.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,457.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,360.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,457.38,
ADV O S 70 ANTI ROT 8021-070,2111328,CDM,278,RC,,,both,,,571.72,343.03,,428.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,428.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,371.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,122.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,457.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,360.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,457.38,
ADV O S 70 ANTI ROT 8021-090,2111354,CDM,278,RC,,,both,,,571.72,343.03,,428.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,428.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,371.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,122.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,457.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,360.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,457.38,
ADV O S 90 ROTATION SCREW 8021-095,2111440,CDM,278,RC,,,both,,,675.27,405.16,,506.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,506.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,438.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,145.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,506.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,425.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.36,540.22,
ADV O S BALL NOSE GUIDE 900MM 0101-001,2111330,CDM,278,RC,,,both,,,421.28,252.77,,315.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,315.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,273.83,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,90.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,315.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,337.02,
ADV O S BALL NOSE GUIDE WIRE 0101-600,2110996,CDM,278,RC,,,both,,,421.28,252.77,,315.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,315.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,273.83,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,90.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,315.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.32,337.02,
ADV O S CALIBRATED DRILL 4.0 0219-100,2110998,CDM,278,RC,,,both,,,491.52,294.91,,368.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,368.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,105.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,393.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,368.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.71,393.22,
ADV O S COM LAG SCREW 10.5X100 1045-105,2111431,CDM,278,RC,,,both,,,851.38,510.83,,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,553.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,183.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,681.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,536.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,681.1,
ADV O S CORT SCREW 5.0 8000-032,2111329,CDM,278,RC,,,both,,,230.75,138.45,,173.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,173.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,49.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,173.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,145.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.28,184.6,
ADV O S CORT SCREW 5.0 8000-036,2110995,CDM,278,RC,,,both,,,230.75,138.45,,173.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,173.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,49.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,173.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,145.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.28,184.6,
ADV O S CORT SCREW 5.0X30 8000-030,2111334,CDM,278,RC,,,both,,,225.13,135.08,,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,146.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,180.1,
ADV O S CORT SCREW 5.0X32 8000-032,2111335,CDM,278,RC,,,both,,,225.13,135.08,,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,146.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,180.1,
ADV O S CORT SCREW 5.0X34 8000-034,2111338,CDM,278,RC,,,both,,,225.13,135.08,,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,146.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,180.1,
ADV O S CORT SCREW 5.0X55 8000-055,2111337,CDM,278,RC,,,both,,,225.13,135.08,,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,146.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,180.1,
ADV O S CORT SCREW 5.0X65 8000-065,2111336,CDM,278,RC,,,both,,,225.13,135.08,,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,146.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,180.1,
ADV O S CORT TAP 0216,2111012,CDM,278,RC,,,both,,,652.03,391.22,,489.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,489.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,140.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,521.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,489.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,410.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.6,521.62,
ADV O S DRILL SHORT 4.0 0210,2110999,CDM,278,RC,,,both,,,471.46,282.88,,353.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,353.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.45,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,101.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,353.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,297.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.6,377.17,
ADV O S END LAP 1015-050,2111268,CDM,278,RC,,,both,,,548.06,328.84,,411.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,411.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,356.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,117.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,411.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,345.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.3,438.45,
ADV O S GREEN RETRO SLEEVE 1005-1004,2111333,CDM,278,RC,,,both,,,773.08,463.85,,579.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,579.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,164.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,502.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,166.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,579.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,579.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,579.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,579.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,487.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.4,618.46,
ADV O S GUIDE PIN 3.2X33 0100,2110997,CDM,278,RC,,,both,,,190.54,114.32,,142.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,142.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,40.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,152.43,
ADV O S LAG SCREW 10.5X100 1045-100,2111355,CDM,278,RC,,,both,,,851.38,510.83,,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,553.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,183.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,681.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,536.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,681.1,
ADV O S LAG SCREW 110 1045-110,2111327,CDM,278,RC,,,both,,,851.38,510.83,,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,553.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,183.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,681.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,536.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,681.1,
ADV O S LAG SCREW 115 1045-115,2111400,CDM,278,RC,,,both,,,851.38,510.83,,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,553.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,183.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,681.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,536.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,681.1,
ADV O S LAG SCREW 120 1045-120,2111401,CDM,278,RC,,,both,,,851.38,510.83,,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,553.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,183.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,681.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,638.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,536.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.45,681.1,
ADV O S LOCKING KING 1000,2111267,CDM,278,RC,,,both,,,225.13,135.08,,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,146.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,180.1,
ADV O S NAIL 1037-200,2111326,CDM,278,RC,,,both,,,3621.07,2172.64,,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2353.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,778.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2896.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2281.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,2896.86,
ADV O S NAIL 1043-200,2111432,CDM,278,RC,,,both,,,3621.07,2172.64,,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2353.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,778.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2896.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2281.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,2896.86,
ADV O S NAIL 130x12 1041-200,2111402,CDM,278,RC,,,both,,,3621.07,2172.64,,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2353.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,778.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2896.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2281.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,2896.86,
ADV O S RETRO NAIL 10X20CM 1010-200,2111332,CDM,278,RC,,,both,,,3209.76,1925.86,,2407.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2407.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,683.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,683.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2086.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,690.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2567.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2407.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2407.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2407.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2407.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,657.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2022.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,657.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,657.68,2567.81,
ALLOGRAFT HEMI PATELLA TENDON,2111122,CDM,278,RC,,,both,,,3911.86,2347.12,,2933.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2933.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,833.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2542.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,841.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3129.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2933.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2933.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2933.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2933.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,801.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2464.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,801.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,801.54,3129.49,
ALLOGRAFT PATELLA TENDON 46B005,2110957,CDM,278,RC,,,both,,,6160.75,3696.45,,4620.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4620.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1312.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1312.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4004.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1324.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4928.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4620.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4620.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4620.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4620.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1262.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3881.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1262.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1262.34,4928.6,
AMS MONARC SUBFACIAL HAMMOCK 72403830,2111977,CDM,278,RC,C1771,HCPCS,both,,,2655.86,1593.52,,1991.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1991.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,565.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,565.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1726.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,571.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2124.69,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1991.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1991.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1991.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1991.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1673.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544.19,2124.69,
ANGIO DYN GUIDEWIRE 05500501,2109422,CDM,278,RC,C1769,HCPCS,both,,,80.95,48.57,,60.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,60.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,17.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,60.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.59,64.76,
ANGIO DYN WH BALLOON 7X2X50 16500403,2109574,CDM,278,RC,C1725,HCPCS,both,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,248.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,264.8,
ANGIO DYN WORKHORSE 9X2X50 16500437,2109575,CDM,278,RC,C1725,HCPCS,both,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,248.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,264.8,
ANGIO DYN WORKHORSE 9X4X50 16500443,2109576,CDM,278,RC,C1725,HCPCS,both,,,331,198.6,,248.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,248.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,71.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.82,264.8,
ANGIO DYN X-RAY DUAL LUMEN PICC MR371511,2110735,CDM,278,RC,C1751,HCPCS,both,,,439.11,263.47,,329.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,329.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,285.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,94.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,329.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,276.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.97,351.29,
ANTIBIOTIC BONE CEMENT 40GRAMS,2113041,CDM,278,RC,,,both,,,1083.45,650.07,,812.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,812.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,704.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,232.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,812.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,812.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,682.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222,866.76,
APPLIED MED THROMB CATH 4X80 A4548,2109455,CDM,278,RC,C1757,HCPCS,both,,,374.08,224.45,,280.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,280.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,243.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,80.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.65,299.26,
ARTHREX 2.4 MINI SUTURETAK AR-1322BCNF,2111776,CDM,278,RC,C1713,HCPCS,both,,,1072.47,643.48,,804.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,804.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,697.11,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,230.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,804.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,804.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,675.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.75,857.98,
ARTHREX 2.4 SUTURETAK AR-1320BCNF,2113069,CDM,278,RC,C1713,HCPCS,both,,,986.64,591.98,,739.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,739.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,210.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,641.32,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,212.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,739.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,739.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,739.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,739.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,621.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.16,789.31,
ARTHREX 3.0 SUTURE ANCHOR AR1934BF-2,2110980,CDM,278,RC,C1713,HCPCS,both,,,655.64,393.38,,491.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,491.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,426.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,140.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.51,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,491.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,413.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.34,524.51,
ARTHREX 5.5 CORKSCREW AR-1927BF,2110800,CDM,278,RC,C1713,HCPCS,both,,,628.9,377.34,,471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,408.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,135.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,396.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,503.12,
ARTHREX ACL DISP KIT AR-1898S,2112017,CDM,278,RC,C1713,HCPCS,both,,,496.72,298.03,,372.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,372.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,322.87,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,106.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,372.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,312.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.78,397.38,
ARTHREX ACL TIGHTROPE AR-1588RT-11,2112246,CDM,278,RC,C1713,HCPCS,both,,,1740.62,1044.37,,1305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1131.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,374.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1392.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1096.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.65,1392.5,
ARTHREX ACL TIGHTROPE AR-1588RTS,2112018,CDM,278,RC,C1713,HCPCS,both,,,1266.5,759.9,,949.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,949.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,269.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,823.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,272.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1013.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,949.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,949.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,797.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.51,1013.2,
ARTHREX ACL TIGHTROPE AR-1588T,2111900,CDM,278,RC,C1713,HCPCS,both,,,938.58,563.15,,703.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,703.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,610.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,703.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,591.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.32,750.86,
ARTHREX BIO COMP INTERF SCREW AR-1400C,2111896,CDM,278,RC,C1713,HCPCS,both,,,768.94,461.36,,576.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,576.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,499.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,165.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,615.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,484.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,615.15,
ARTHREX BIO CORKSCREW NEEDAR1927BCNF,2112217,CDM,278,RC,,,both,,,1110.55,666.33,,832.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,832.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,236.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,721.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,238.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,888.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,832.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,832.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,832.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,832.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,699.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.55,888.44,
ARTHREX BIO CORKSCREW NEEDLES AR1927BNF,2111018,CDM,278,RC,,,both,,,1007.75,604.65,,755.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,755.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,214.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,655.04,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,216.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,806.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,755.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,755.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,634.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.49,806.2,
ARTHREX BIO PUSH LOCK AR-1922B,2110812,CDM,278,RC,C1713,HCPCS,both,,,1160.62,696.37,,870.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,870.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,247.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,754.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,249.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,928.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,870.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,731.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.81,928.5,
ARTHREX BONE VOID FILLER,2112647,CDM,278,RC,,,both,,,1081.8,649.08,,811.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,811.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,703.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,232.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,865.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,811.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.66,865.44,
ARTHREX CANCELLOUS SCREWS AR-14230,2111025,CDM,278,RC,C1713,HCPCS,both,,,180.57,108.34,,135.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,135.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,38.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,135.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37,144.46,
ARTHREX CANNULA AR-6530,2111229,CDM,278,RC,,,both,,,167.2,100.32,,125.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,125.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,133.76,
ARTHREX CANNULA BLUE AR-6540,2111022,CDM,278,RC,,,both,,,172.22,103.33,,129.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,129.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,37.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,129.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,108.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.29,137.78,
ARTHREX CANNULA YELLOW AR-6530,2111558,CDM,278,RC,,,both,,,167.2,100.32,,125.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,125.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,133.76,
ARTHREX CMC MINI TIGHTROPE AR-8914DS,2112817,CDM,278,RC,C1713,HCPCS,both,,,1434.23,860.54,,1075.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1075.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,305.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,932.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,308.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1147.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1075.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,903.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.87,1147.38,
ARTHREX CMC MINI TIGHTROPE AR-8919DS,2112717,CDM,278,RC,C1713,HCPCS,both,,,2442.51,1465.51,,1831.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1831.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,520.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1587.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,525.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1954.01,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1831.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1831.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1831.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1831.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,500.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1538.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,500.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,500.47,1954.01,
ARTHREX COMP SCREW AR-8730-28H,2112641,CDM,278,RC,C1713,HCPCS,both,,,644.71,386.83,,483.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,483.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,419.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,138.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,515.77,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,483.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,406.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.1,515.77,
ARTHREX CORT SCREW AR14126/32/30,2111026,CDM,278,RC,C1713,HCPCS,both,,,180.57,108.34,,135.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,135.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,38.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,135.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37,144.46,
ARTHREX DISP PUNCH AR-1927PBS,2111028,CDM,278,RC,,,both,,,150.43,90.26,,112.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,112.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,32.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,112.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.82,120.34,
ARTHREX DOG BONE AR-2270,2112068,CDM,278,RC,C1713,HCPCS,both,,,1044.77,626.86,,783.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,783.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,222.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,222.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,679.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,224.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,835.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,783.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,783.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,658.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.07,835.82,
ARTHREX DRILL BIT 2.5 AR-4160-25,2112364,CDM,278,RC,,,both,,,177.81,106.69,,133.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,133.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,38.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,112.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.43,142.25,
ARTHREX FIBER STICK AR-7209,2111846,CDM,278,RC,,,both,,,130.39,78.23,,97.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,97.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,28.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,97.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.72,104.31,
ARTHREX FIBER STITCH IMPLANT AR-4570,2113206,CDM,278,RC,C1776,HCPCS,both,,,1050.29,630.17,,787.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,787.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,682.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,225.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,840.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,787.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,787.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,661.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.2,840.23,
ARTHREX FIBERSNARE AR-7209SN,2112071,CDM,278,RC,,,both,,,238.81,143.29,,179.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,179.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,179.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,150.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.93,191.05,
ARTHREX FIBERTAPE AR-7237,2112069,CDM,278,RC,,,both,,,406.85,244.11,,305.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,305.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,264.45,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,87.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,305.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,256.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.36,325.48,
ARTHREX FIBERWIRE AR-7200,2111070,CDM,278,RC,,,both,,,127.41,76.45,,95.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,95.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,27.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.11,101.93,
ARTHREX FIBERWIRE AR-7202,2111709,CDM,278,RC,,,both,,,106.41,63.85,,79.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,79.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,22.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.13,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,79.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.8,85.13,
ARTHREX FIBERWIRE AR-7211,2110950,CDM,278,RC,,,both,,,255.42,153.25,,191.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,191.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,54.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,160.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,204.34,
ARTHREX FIBERWIRE AR-7270,2111017,CDM,278,RC,,,both,,,300.98,180.59,,225.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,225.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,195.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,64.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,225.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.67,240.78,
ARTHREX FULL THREADED SCREW AR-1371T,2110731,CDM,278,RC,C1713,HCPCS,both,,,209.64,125.78,,157.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,157.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,45.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.71,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,157.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,132.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.96,167.71,
ARTHREX HUMERAL SUTURE PLATE AR-14000,2111027,CDM,278,RC,C1713,HCPCS,both,,,2106.42,1263.85,,1579.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1579.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,448.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,448.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1369.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,452.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1685.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1579.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1579.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1579.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1579.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1327.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.61,1685.14,
ARTHREX IMPLANT AR-8925T,2113102,CDM,278,RC,C1776,HCPCS,both,,,4084.61,2450.77,,3063.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3063.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,870.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,870.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2655,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,878.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3267.69,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3063.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3063.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3063.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3063.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,836.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2573.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,836.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,836.94,3267.69,
ARTHREX IMPLANT AR-8928C-CP,2112231,CDM,278,RC,C1776,HCPCS,both,,,4812.14,2887.28,,3609.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3609.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1024.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1024.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3127.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1034.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3849.71,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3609.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3609.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3609.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3609.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,986.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3031.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,986.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,986.01,3849.71,
ARTHREX IMPLANT PUSHLOCK AR-1926BC,2112106,CDM,278,RC,C1713,HCPCS,both,,,1126.68,676.01,,845.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,845.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,732.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,242.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,901.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,845.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,709.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.86,901.34,
ARTHREX K WIRE AR-14016,2111029,CDM,278,RC,,,both,,,86.99,52.19,,65.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,65.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,18.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.59,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,65.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,69.59,
ARTHREX K WIRE BB TAK AR-13226,2112365,CDM,278,RC,,,both,,,135.05,81.03,,101.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,101.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,29.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,101.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.67,108.04,
ARTHREX LASSO 25DEGREE W/F S AR-4068-25,2111847,CDM,278,RC,,,both,,,504.25,302.55,,378.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,378.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,327.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,108.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,403.4,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,378.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,317.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.32,403.4,
ARTHREX MENISCAL CINCH AR-4500,2111965,CDM,278,RC,,,both,,,660.84,396.5,,495.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,495.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,429.55,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,142.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,528.67,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,495.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,416.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.41,528.67,
ARTHREX METAL SCREW,2111743,CDM,278,RC,C1713,HCPCS,both,,,268.09,160.85,,201.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,201.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,57.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.47,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,201.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.93,214.47,
ARTHREX MINI ANCHOR AR-1322-752SF,2112575,CDM,278,RC,C1713,HCPCS,both,,,596.55,357.93,,447.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,447.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,387.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,128.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,447.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,375.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.23,477.24,
ARTHREX MINI TIGHTROPE AR-8914DS,2112694,CDM,278,RC,C1713,HCPCS,both,,,1434.23,860.54,,1075.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1075.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,305.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,932.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,308.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1147.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1075.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,903.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.87,1147.38,
ARTHREX PLATE MED AR-8951MR,2112362,CDM,278,RC,C1713,HCPCS,both,,,1912.28,1147.37,,1434.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1434.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,407.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1242.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,411.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1529.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1434.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1204.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.83,1529.82,
ARTHREX PUSHLOCK AR-1923BC,2111708,CDM,278,RC,C1713,HCPCS,both,,,1258.97,755.38,,944.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,944.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,268.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,818.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,270.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1007.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,944.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,944.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,944.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,944.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,793.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.96,1007.18,
ARTHREX PUSHLOCK AR-1926DS,2111078,CDM,278,RC,C1713,HCPCS,both,,,405.8,243.48,,304.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,304.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,263.77,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,87.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,304.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,255.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.15,324.64,
ARTHREX PUSHLOCK AR-1926PS,2110799,CDM,278,RC,C1713,HCPCS,both,,,1126.78,676.07,,845.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,845.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,732.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,242.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,901.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,845.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,709.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.88,901.42,
ARTHREX PUSHLOCK KIT AR-1923DS,2111848,CDM,278,RC,C1713,HCPCS,both,,,562.81,337.69,,422.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,422.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,365.83,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,121,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,422.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,354.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.32,450.25,
ARTHREX ROUND DEL BIO COMP AR-5028C-09,2112019,CDM,278,RC,C1713,HCPCS,both,,,768.94,461.36,,576.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,576.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,499.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,165.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,615.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,484.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,615.15,
ARTHREX ROUND DELTA BIO COMP AR-5028C-08,2111521,CDM,278,RC,C1713,HCPCS,both,,,756.32,453.79,,567.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,567.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,161.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,491.61,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,162.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,605.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,567.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,567.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,567.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,567.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,476.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.97,605.06,
ARTHREX SCORPION NEEDLE AR-1399,2110811,CDM,278,RC,C1713,HCPCS,both,,,500.58,300.35,,375.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,375.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,325.38,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,107.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,375.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,315.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.57,400.46,
ARTHREX SCREW 9X28MM AR-1390TC,2111716,CDM,278,RC,C1713,HCPCS,both,,,656.17,393.7,,492.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,492.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,426.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,141.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,492.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,413.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.45,524.94,
ARTHREX SCREW AR-8935L-32,2112363,CDM,278,RC,C1713,HCPCS,both,,,168.79,101.27,,126.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,126.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,36.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,126.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,106.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,135.03,
ARTHREX SCREW BIO COM AR-5035TC-09,2111522,CDM,278,RC,C1713,HCPCS,both,,,768.94,461.36,,576.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,576.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,499.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,165.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,615.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,484.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,615.15,
ARTHREX SCREW BIO COMP AR-1390C,2111524,CDM,278,RC,C1713,HCPCS,both,,,768.94,461.36,,576.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,576.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,499.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,165.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,615.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,484.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.56,615.15,
ARTHREX SCREW CANNULATED AR-1391T/1381T,2111063,CDM,278,RC,C1713,HCPCS,both,,,190.54,114.32,,142.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,142.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,40.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.04,152.43,
ARTHREX SCREW INTERFERENCE AR-1404TC,2112247,CDM,278,RC,C1713,HCPCS,both,,,746.55,447.93,,559.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,559.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,159.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,485.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,160.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,597.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,559.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,470.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.97,597.24,
ARTHREX SCREW SHEATHED AR-1381E/1380E,2111089,CDM,278,RC,C1713,HCPCS,both,,,290.9,174.54,,218.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,218.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,62.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,218.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,183.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.61,232.72,
ARTHREX STRAIGHT SUTURE LASSO AR-4068-90,2112243,CDM,278,RC,,,both,,,373.33,224,,280,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,280,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,242.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,80.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,298.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,280,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,235.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.5,298.66,
ARTHREX SUTURE ANCHOR 5.5 AR-2923BC,2110981,CDM,278,RC,C1713,HCPCS,both,,,1126.68,676.01,,845.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,845.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,732.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,242.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,901.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,845.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,709.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.86,901.34,
ARTHREX TIGERTAPE AR-7237-7T,2112070,CDM,278,RC,,,both,,,260.88,156.53,,195.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,195.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,56.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,208.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,195.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,164.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.45,208.7,
ARTHREX TRANSTIBIAL KIT AR-1898S,2111062,CDM,278,RC,C1713,HCPCS,both,,,398.8,239.28,,299.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,299.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.22,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,85.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,299.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,251.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.71,319.04,
ARTHREX TRANSTIBIAL KIT AR-1898S,2111064,CDM,278,RC,C1713,HCPCS,both,,,290.9,174.54,,218.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,218.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,62.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,218.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,183.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.61,232.72,
AUSTIN MOORE HIP STEM,2109762,CDM,278,RC,C1713,HCPCS,both,,,1615.33,969.2,,1211.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1211.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,344.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1049.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,347.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1292.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1211.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1211.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1211.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1211.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1017.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.98,1292.26,
BARD ATLAS BALLOON AT-75144,2109405,CDM,278,RC,C1725,HCPCS,both,,,805.44,483.26,,604.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,604.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,523.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,173.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,644.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,604.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,507.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.03,644.35,
BARD COMPOIR MESH 4X8,2108438,CDM,278,RC,C1781,HCPCS,both,,,1108.86,665.32,,831.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,831.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,236.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,720.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,238.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,887.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,831.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,831.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,831.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,831.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,698.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.21,887.09,
BARD CONQUEST BALLOON CQ-5072,2109415,CDM,278,RC,C1725,HCPCS,both,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,393.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,341.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,420.2,
BARD CONQUEST BALLOON CQ-5078,2109746,CDM,278,RC,C1725,HCPCS,both,,,639.94,383.96,,479.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,479.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,415.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,137.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.95,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,479.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,403.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.12,511.95,
BARD CONQUEST BALLOON CQ-5088,2109583,CDM,278,RC,C1725,HCPCS,both,,,628.9,377.34,,471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,408.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,135.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,396.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,503.12,
BARD CONQUEST BALLOON CQ-7564,2109582,CDM,278,RC,C1725,HCPCS,both,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,393.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,341.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,420.2,
BARD CONQUEST BALLOON CQ-7594,2109520,CDM,278,RC,C1725,HCPCS,both,,,525.25,315.15,,393.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,393.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,341.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,420.2,
BARD CONQUEST PTA BALLOON CQ-5058,2109695,CDM,278,RC,C1725,HCPCS,both,,,628.9,377.34,,471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,408.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,135.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,396.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,503.12,
BARD CONQUEST PTA BALLOON CQ-5068,2109696,CDM,278,RC,C1725,HCPCS,both,,,628.9,377.34,,471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,408.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,135.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,396.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.86,503.12,
BARD CT PORT A CATH 1808560,2111396,CDM,278,RC,C1788,HCPCS,both,,,1161.29,696.77,,870.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,870.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,247.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,754.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,249.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,929.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,870.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,870.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,731.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.95,929.03,
BARD CT PORT A CATH 6F SLIM 1716070,2112205,CDM,278,RC,C1788,HCPCS,both,,,936.46,561.88,,702.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,702.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,608.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,749.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,702.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,589.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.88,749.17,
BARD CT PORT A CATH 8F SLIM 1718501,2112206,CDM,278,RC,C1788,HCPCS,both,,,1988.13,1192.88,,1491.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1491.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1292.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,427.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1590.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1491.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1491.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1491.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1491.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1252.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.37,1590.5,
BARD FLUENCY COVERED STENT FLT08040,2109409,CDM,278,RC,C1874,HCPCS,both,,,4623.08,2773.85,,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3005,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,993.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3698.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2912.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,3698.46,
BARD FLUENCY COVERED STENT FLT10040,2109410,CDM,278,RC,,,both,,,4623.08,2773.85,,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3005,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,993.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3698.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2912.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,3698.46,
BARD FLUENCY COVERED STENT FTM07040,2109407,CDM,278,RC,C1875,HCPCS,both,,,4623.08,2773.85,,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3005,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,993.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3698.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2912.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,3698.46,
BARD FLUENCY COVERED STENT FTM07060,2109408,CDM,278,RC,C1874,HCPCS,both,,,4623.08,2773.85,,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3005,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,993.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3698.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2912.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,3698.46,
BARD FLUENCY COVERED STENT FTM07080,2109774,CDM,278,RC,C1875,HCPCS,both,,,5284.34,3170.6,,3963.26,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3963.26,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1125.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1125.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3434.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1136.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4227.47,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3963.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3963.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3963.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3963.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3329.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1082.76,4227.47,
BARD FLUENCY TRACH STENT FLT08040,2109605,CDM,278,RC,C1874,HCPCS,both,,,4623.08,2773.85,,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3005,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,993.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3698.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2912.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,3698.46,
BARD FLUENCY TRACH STENT FLT08060,2109602,CDM,278,RC,,,both,,,4623.08,2773.85,,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3005,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,993.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3698.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2912.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,3698.46,
BARD FLUENCY TRACH STENT FTM08060,2109859,CDM,278,RC,C1874,HCPCS,both,,,4623.08,2773.85,,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3005,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,993.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3698.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2912.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,3698.46,
BARD FLUENCY TRACH STENT FTM10060,2109603,CDM,278,RC,C1875,HCPCS,both,,,4623.08,2773.85,,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,984.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3005,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,993.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3698.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3467.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2912.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,947.27,3698.46,
BARD GROSHONG CATH 0607510,2112281,CDM,278,RC,C1788,HCPCS,both,,,659.35,395.61,,494.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,494.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,428.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,141.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,494.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,415.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.1,527.48,
BARD GROSHONG CATH 8FR 7711800,2111349,CDM,278,RC,C1751,HCPCS,both,,,412.24,247.34,,309.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,309.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,267.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,88.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,329.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,309.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,259.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.47,329.79,
BARD HEMO-SPLIT 23CM 5703730,2109330,CDM,278,RC,C1750,HCPCS,both,,,827.5,496.5,,620.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,620.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,537.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,177.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,662,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,521.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,662,
BARD HEMO-SPLIT 27CM 5703270,2109333,CDM,278,RC,C1750,HCPCS,both,,,827.5,496.5,,620.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,620.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,537.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,177.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,662,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,521.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,662,
BARD HEMO-SPLIT 35CM 5703350,2109331,CDM,278,RC,C1750,HCPCS,both,,,827.5,496.5,,620.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,620.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,537.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,177.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,662,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,521.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.55,662,
BARD ISP 8.0 FR INTER 0607540,2112325,CDM,278,RC,C1788,HCPCS,both,,,639.52,383.71,,479.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,479.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,415.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,137.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,479.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,402.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.04,511.62,
BARD ISP PORT A CATH 7707540,2109332,CDM,278,RC,C1788,HCPCS,both,,,1657.23,994.34,,1242.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1242.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,352.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1077.2,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,356.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1325.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1242.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1242.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1242.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1242.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1044.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.57,1325.78,
BARD LUMINEXX STENT LUB07040,2109395,CDM,278,RC,C1876,HCPCS,both,,,2979.11,1787.47,,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1936.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,640.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2383.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1876.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,2383.29,
BARD LUMINEXX STENT LUB08040,2109397,CDM,278,RC,C1876,HCPCS,both,,,2979.11,1787.47,,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1936.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,640.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2383.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1876.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,2383.29,
BARD LUMINEXX STENT LUB08060,2109398,CDM,278,RC,C1876,HCPCS,both,,,3078.31,1846.99,,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2000.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,661.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2462.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1939.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,2462.65,
BARD LUMINEXX STENT LUB09040,2109399,CDM,278,RC,C1876,HCPCS,both,,,2979.11,1787.47,,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1936.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,640.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2383.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1876.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,2383.29,
BARD LUMINEXX STENT LUB10060,2109401,CDM,278,RC,C1876,HCPCS,both,,,2979.11,1787.47,,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1936.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,640.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2383.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1876.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,2383.29,
BARD LUMINEXX STENT LUB12040,2109402,CDM,278,RC,C1877,HCPCS,both,,,2979.11,1787.47,,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,634.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1936.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,640.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2383.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2234.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1876.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.42,2383.29,
BARD LUMINEXX STENT LUB12060,2109403,CDM,278,RC,C1877,HCPCS,both,,,3078.31,1846.99,,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2000.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,661.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2462.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1939.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,2462.65,
BARD LUMINEXX STENT LUB9060,2109561,CDM,278,RC,C1876,HCPCS,both,,,3078.31,1846.99,,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2000.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,661.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2462.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1939.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,2462.65,
BARD LUMINEXX STENT LUBO7060,2109396,CDM,278,RC,C1877,HCPCS,both,,,3078.31,1846.99,,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2000.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,661.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2462.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1939.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,2462.65,
BARD LUMINIXX STENT LUB10040,2109400,CDM,278,RC,C1877,HCPCS,both,,,3078.31,1846.99,,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,655.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2000.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,661.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2462.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2308.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1939.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,630.75,2462.65,
BARD MRI HARD BASE IMPLANTED PORT,2108910,CDM,278,RC,C1788,HCPCS,both,,,1430.52,858.31,,1072.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1072.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,304.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,929.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,307.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1144.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1072.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,901.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.11,1144.42,
BARD PTA BALLOON CATH XT-7552,2109589,CDM,278,RC,C1725,HCPCS,both,,,474.44,284.66,,355.83,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,355.83,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,308.39,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,102,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.55,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,298.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.21,379.55,
BARTHOLIN GLAND CATH 56400,2109237,CDM,278,RC,C1729,HCPCS,both,,,147.79,88.67,,110.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,110.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,31.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.28,118.23,
BIOME 100 DEGREE TUBULAR PLATE T SMALL F,2109788,CDM,278,RC,C1713,HCPCS,both,,,154.62,92.77,,115.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,115.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,33.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.68,123.7,
BIOME 4.0 SOLID SCREW F THREADED T SMALL,2109792,CDM,278,RC,C1713,HCPCS,both,,,273.19,163.91,,204.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,204.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,177.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,58.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.55,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,172.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.98,218.55,
BIOME 4.5MM CORT FULLY THREADED T LG FRA,2111672,CDM,278,RC,C1713,HCPCS,both,,,258.97,155.38,,194.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,194.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,168.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,55.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,194.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.06,207.18,
BIOME ACTIVE COMPRESSION PLATE T SM FRAG,2109789,CDM,278,RC,C1713,HCPCS,both,,,388.73,233.24,,291.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,291.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,252.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,244.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,310.98,
BIOME CROSS-LINK STAB INSERT 1581-25-112,2111842,CDM,278,RC,C1776,HCPCS,both,,,6477.96,3886.78,,4858.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4858.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1379.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1379.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4210.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1392.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5182.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4858.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4858.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4858.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4858.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4081.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1327.33,5182.37,
BIOME DORSAL DISTAL RADIUS PLATE UPPER E,2109802,CDM,278,RC,C1713,HCPCS,both,,,662.47,397.48,,496.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,496.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,430.61,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,142.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,496.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,417.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.74,529.98,
BIOMET 1.2 K WIRE T SMALL FRAG,2109855,CDM,278,RC,C1713,HCPCS,both,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,48.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,13.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,51.36,
BIOMET 1/4 TUBULAR PLATE MINI FRAG,2109783,CDM,278,RC,C1713,HCPCS,both,,,184.95,110.97,,138.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,138.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.22,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,39.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.96,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.9,147.96,
BIOMET 100 DEG TUB 4 HOLE 14355-2/3/4,2111619,CDM,278,RC,C1713,HCPCS,both,,,176.48,105.89,,132.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,132.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,37.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,111.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.16,141.18,
BIOMET 2.9MM S COUPLE T SMALL FRAG,2109851,CDM,278,RC,C1713,HCPCS,both,,,520.95,312.57,,390.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,390.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,338.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,390.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,390.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.74,416.76,
BIOMET 22MM THREADED LAG SCREW,2109827,CDM,278,RC,C1713,HCPCS,both,,,699.07,419.44,,524.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,524.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,454.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,150.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,559.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,524.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,440.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.24,559.26,
BIOMET 3.5 SCREW 32MM-70MM,2109795,CDM,278,RC,C1713,HCPCS,both,,,249.41,149.65,,187.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,187.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,53.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.53,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,157.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.1,199.53,
BIOMET 3.5 SCREW T SM FRAG10MM-30MM,2111593,CDM,278,RC,C1713,HCPCS,both,,,77.25,46.35,,57.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,57.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,16.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,57.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.83,61.8,
BIOMET 3.5 SCREW T SM FRAG75MM-120MM,2111594,CDM,278,RC,C1713,HCPCS,both,,,150.52,90.31,,112.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,112.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,32.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,120.42,
BIOMET 6.5 SCREW X25/30/35/40,2113132,CDM,278,RC,C1713,HCPCS,both,,,247.61,148.57,,185.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,185.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,160.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,53.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,185.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.74,198.09,
BIOMET 6.5 SOLID CANCEL T 14584,2109816,CDM,278,RC,,,both,,,281.39,168.83,,211.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,211.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,182.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,60.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.11,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,177.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,225.11,
BIOMET 65MM/6.5 CANC BONE SCREW,2109805,CDM,278,RC,C1713,HCPCS,both,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,192.98,
BIOMET 8 HOLE COMPOALE LOCK PLATE,2112252,CDM,278,RC,C1713,HCPCS,both,,,603.73,362.24,,452.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,452.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,392.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,129.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,380.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.7,482.98,
BIOMET AC JOINT DISP SYSTEM 904837,2112038,CDM,278,RC,,,both,,,1165.13,699.08,,873.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,873.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,757.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,250.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,932.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,873.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,873.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,734.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.74,932.1,
BIOMET BENDING TEMPLATE 8241-74-000,2110274,CDM,278,RC,,,both,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,150.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,43.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,160.86,
BIOMET BENDING TEMPLATE T SMALL FRAG,2109850,CDM,278,RC,C1713,HCPCS,both,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,150.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,43.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,160.86,
BIOMET BROAD PLATE T LG FRAG,2109810,CDM,278,RC,C1713,HCPCS,both,,,626.95,376.17,,470.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,470.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,407.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,134.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,501.56,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,470.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,394.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.46,501.56,
BIOMET CALC PERIMETER PLATE LOWER EXT,2109798,CDM,278,RC,C1713,HCPCS,both,,,988.65,593.19,,741.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,741.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,210.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,642.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,212.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,790.92,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,741.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,741.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,622.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.57,790.92,
BIOMET CANCELLOUS 14627,2109817,CDM,278,RC,,,both,,,281.39,168.83,,211.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,211.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,182.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,60.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.11,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,177.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,225.11,
BIOMET CANN CANC LAG SCR (OR,2109794,CDM,278,RC,C1713,HCPCS,both,,,348.85,209.31,,261.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,261.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.08,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,261.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,219.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.48,279.08,
BIOMET CANNULATED DRILL 14629,2109818,CDM,278,RC,,,both,,,704.81,422.89,,528.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,528.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,458.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,151.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,528.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,444.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.42,563.85,
BIOMET COMP HMRL BRNG XL-115363,2112212,CDM,278,RC,C1713,HCPCS,both,,,1737.99,1042.79,,1303.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1303.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1129.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,373.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1390.39,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1303.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1303.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1303.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1303.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1094.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.11,1390.39,
BIOMET COMP PRIMARY STEM 113653,2112211,CDM,278,RC,C1776,HCPCS,both,,,6495.45,3897.27,,4871.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4871.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1383.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1383.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4222.04,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1396.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5196.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4871.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4871.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4871.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4871.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1330.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4092.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1330.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1330.92,5196.36,
BIOMET COMP RVS TRAY 115370,2112210,CDM,278,RC,C1776,HCPCS,both,,,3012.65,1807.59,,2259.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2259.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,641.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1958.22,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,647.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2410.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2259.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2259.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,617.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1897.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,617.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,617.29,2410.12,
BIOMET CONDYLAR PLATE MINI FRAG,2109782,CDM,278,RC,C1713,HCPCS,both,,,528.06,316.84,,396.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,396.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,343.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,113.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,396.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.2,422.45,
BIOMET CORTICAL SCREWS MINI FRAG,2109831,CDM,278,RC,C1713,HCPCS,both,,,345.58,207.35,,259.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,259.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,224.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,74.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,259.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,217.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.81,276.46,
BIOMET CORTICAL TAP MINI FRAG,2109828,CDM,278,RC,C1713,HCPCS,both,,,159.54,95.72,,119.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,119.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,34.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.63,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.69,127.63,
BIOMET COUNTESINK 3.5 DIA T SMALL FRAG,2109857,CDM,278,RC,C1713,HCPCS,both,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,216.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.28,231.44,
BIOMET CUP WASHER 14261,2109848,CDM,278,RC,C1713,HCPCS,both,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,192.98,
BIOMET DRILL NIT SHORT,2109938,CDM,278,RC,,,both,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,144.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,41.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,154.3,
BIOMET DRILL TWIST SCP 2.9X70MM,2113001,CDM,278,RC,C1713,HCPCS,both,,,477.25,286.35,,357.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,357.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,310.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,102.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,357.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,300.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.79,381.8,
BIOMET DRILL TWIST SCP 3.5X70MM,2113002,CDM,278,RC,C1713,HCPCS,both,,,238.76,143.26,,179.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,179.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.19,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.01,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,179.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,150.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.92,191.01,
BIOMET FIBULAR COMPOSITE PLATE LOWER EXT,2109796,CDM,278,RC,C1713,HCPCS,both,,,372.89,223.73,,279.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,279.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,242.38,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,80.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,298.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,234.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,298.31,
BIOMET FLAT WASHER 14260,2109849,CDM,278,RC,C1713,HCPCS,both,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,192.98,
BIOMET FULLY THREADED HIP SCREW,2109821,CDM,278,RC,C1713,HCPCS,both,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,150.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,43.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,160.86,
BIOMET GUIDE PIN 14012-9,2109813,CDM,278,RC,C1713,HCPCS,both,,,231.12,138.67,,173.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,173.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,49.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,173.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,145.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.36,184.9,
BIOMET K WIRE,2109786,CDM,278,RC,C1713,HCPCS,both,,,37.15,22.29,,27.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,27.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,7.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.61,29.72,
BIOMET K WIRE,2109937,CDM,278,RC,,,both,,,136.59,81.95,,102.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,102.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,29.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.27,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.99,109.27,
BIOMET K WIRE 8290-16-006,2109785,CDM,278,RC,C1713,HCPCS,both,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,103.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,29.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.59,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.33,110.59,
BIOMET K WIRE MINI FRAG,2109829,CDM,278,RC,C1713,HCPCS,both,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,36.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.43,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,10.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.69,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,38.69,
BIOMET K WIRE T SMALL FRAG,2109853,CDM,278,RC,C1713,HCPCS,both,,,152.71,91.63,,114.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,114.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,32.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,122.17,
BIOMET L PLATE MINI FRAG,2109781,CDM,278,RC,C1713,HCPCS,both,,,353.76,212.26,,265.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,265.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,76.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.01,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,222.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,283.01,
BIOMET L PLATE T LG FRAG,2109812,CDM,278,RC,C1713,HCPCS,both,,,578.87,347.32,,434.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,434.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,376.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,124.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,463.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,364.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.61,463.1,
BIOMET LG FRAG SOLID DRILL 824272000,2110825,CDM,278,RC,,,both,,,228.66,137.2,,171.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,171.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,49.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,171.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,144.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.85,182.93,
BIOMET META PLATE LOWER EXT,2109799,CDM,278,RC,C1713,HCPCS,both,,,747.7,448.62,,560.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,560.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,159.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,486.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,160.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,560.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,560.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,471.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.2,598.16,
BIOMET NARROW PLATE T LG FRAG,2109806,CDM,278,RC,C1713,HCPCS,both,,,397.21,238.33,,297.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,297.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.19,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,85.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.77,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,297.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,250.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,317.77,
BIOMET PARTIAL THREADED T SM FRAG,2109793,CDM,278,RC,C1713,HCPCS,both,,,180.85,108.51,,135.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,135.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.55,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,38.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.68,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.06,144.68,
BIOMET PLATE100DEG TUBULAR 6 HOLE,2113000,CDM,278,RC,C1713,HCPCS,both,,,133.31,79.99,,99.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,99.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.65,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,28.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.32,106.65,
BIOMET RADIAL HEAD 11-210031/22,2111992,CDM,278,RC,,,both,,,3634.96,2180.98,,2726.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2726.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,774.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,774.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2362.72,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,781.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2907.97,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2726.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2726.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2726.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2726.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,744.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2290.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,744.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,744.8,2907.97,
BIOMET RADIAL STEM 11-210061/62,2111991,CDM,278,RC,,,both,,,4308.62,2585.17,,3231.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3231.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,917.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,917.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2800.6,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,926.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3446.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3231.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3231.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3231.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3231.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,882.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2714.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,882.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,882.84,3446.9,
BIOMET SCREW 230125/230425,2110956,CDM,278,RC,,,both,,,425.35,255.21,,319.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,319.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,276.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,91.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.28,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,267.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,340.28,
BIOMET SCREW LOCK 3.5,2112254,CDM,278,RC,,,both,,,227.29,136.37,,170.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,170.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,147.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.83,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,170.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.57,181.83,
BIOMET SCREW MULTIDIRECT,2112255,CDM,278,RC,,,both,,,389.01,233.41,,291.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,291.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,252.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.21,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,291.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,245.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.71,311.21,
BIOMET SCREW NON LOCK 3.5,2112253,CDM,278,RC,,,both,,,227.29,136.37,,170.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,170.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,147.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.83,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,170.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.57,181.83,
BIOMET SHOU DRILL BIT 405889,2112209,CDM,278,RC,,,both,,,592.81,355.69,,444.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,444.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,385.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,127.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,474.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,444.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,444.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,373.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.47,474.25,
BIOMET SHOU FIXED LOC SCREW 180500,2111908,CDM,278,RC,,,both,,,306.52,183.91,,229.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,229.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,65.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,245.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,229.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,193.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.81,245.22,
BIOMET SHOU GLENOSPHERE BASE PLATE 11533,2111912,CDM,278,RC,,,both,,,2943.27,1765.96,,2207.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2207.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,626.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,626.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1913.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,632.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2354.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2207.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1854.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.08,2354.62,
BIOMET SHOU HUMERAL 115340,2111910,CDM,278,RC,,,both,,,3205.78,1923.47,,2404.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2404.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,682.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,682.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2083.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,689.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2564.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2404.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2404.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2404.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2404.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2019.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656.86,2564.62,
BIOMET SHOU SCREW 6.5MM 115383,2111916,CDM,278,RC,,,both,,,304.06,182.44,,228.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,228.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,65.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,191.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.3,243.25,
BIOMET SHOU STEM STD 113649,2111913,CDM,278,RC,,,both,,,6918.6,4151.16,,5188.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5188.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1473.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1473.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4497.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1487.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5534.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5188.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5188.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5188.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5188.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1417.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4358.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1417.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1417.62,5534.88,
BIOMET SHOU STIENMAN PIN 405800,2111914,CDM,278,RC,,,both,,,299.96,179.98,,224.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,224.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,64.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.97,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,224.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,188.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.46,239.97,
BIOMET SHOU VERSA DIAL 118001,2111911,CDM,278,RC,,,both,,,388.73,233.24,,291.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,291.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,252.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,244.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,310.98,
BIOMET SHOUHUMERAL BEARING XL-115363,2111915,CDM,278,RC,,,both,,,1737.99,1042.79,,1303.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1303.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1129.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,373.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1390.39,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1303.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1303.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1303.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1303.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1094.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.11,1390.39,
BIOMET SHOULDER REV GLENOSPHERE 115310,2111907,CDM,278,RC,,,both,,,2606.97,1564.18,,1955.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1955.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,555.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1694.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,560.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2085.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1955.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1642.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.17,2085.58,
BIOMET SOLID DRILL,2109804,CDM,278,RC,,,both,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,192.98,
BIOMET SOLID DRILL 3.8x7 14545,2109815,CDM,278,RC,,,both,,,281.39,168.83,,211.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,211.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,182.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,60.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.11,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,177.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.66,225.11,
BIOMET SPIDER PLATE LOWER EXT,2109797,CDM,278,RC,C1713,HCPCS,both,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,144.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,41.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,154.3,
BIOMET STD/SHORT BARRELL STERILE HIP,2109824,CDM,278,RC,C1713,HCPCS,both,,,1205.55,723.33,,904.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,904.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,783.61,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,259.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,904.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,759.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.02,964.44,
BIOMET STEP WEDGE 1294-56-126,2111746,CDM,278,RC,C1776,HCPCS,both,,,6342.74,3805.64,,4757.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4757.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1351,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1351,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4122.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1363.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5074.19,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4757.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4757.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4757.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4757.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1299.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3995.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1299.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1299.63,5074.19,
BIOMET STRAIGHT PLATE MINI FRAG,2109834,CDM,278,RC,C1713,HCPCS,both,,,438.74,263.24,,329.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,329.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,285.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,94.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.99,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,329.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,276.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.9,350.99,
BIOMET T PLATE MINI FRAG,2109780,CDM,278,RC,C1713,HCPCS,both,,,458.12,274.87,,343.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,343.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,297.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,98.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,366.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,343.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,343.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,288.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.87,366.5,
BIOMET T PLATE T LARGE FRAG,2109811,CDM,278,RC,C1713,HCPCS,both,,,650.99,390.59,,488.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,488.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,139.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,488.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,410.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.39,520.79,
BIOMET WASHER 14097,2109814,CDM,278,RC,C1713,HCPCS,both,,,161.72,97.03,,121.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,121.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,34.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,121.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.14,129.38,
BIOMET WASHER 6.5MM,2109847,CDM,278,RC,C1713,HCPCS,both,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,192.98,
BIOMET WASHER T MINI,2109830,CDM,278,RC,C1713,HCPCS,both,,,144.79,86.87,,108.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,108.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.11,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,31.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.83,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,91.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,115.83,
BIOMET WASHER T SM,2109790,CDM,278,RC,C1713,HCPCS,both,,,273.19,163.91,,204.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,204.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,177.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,58.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.55,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,172.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.98,218.55,
BIOMET ZIPLOOP FIXATION DEV SYS 904834,2112039,CDM,278,RC,,,both,,,1117.32,670.39,,837.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,837.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,237.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,726.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,240.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,837.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,837.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,703.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.94,893.86,
BOS SC GUIDEWIRE 8X4-75 12-552,2109464,CDM,278,RC,C1725,HCPCS,both,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,455.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,394.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,485.46,
BOS SC GUIDEWIRE 8X8-75 12-555,2109463,CDM,278,RC,C1725,HCPCS,both,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,455.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,394.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.34,485.46,
BOS SC PINNACLE 7FR 15-713,2109459,CDM,278,RC,C1894,HCPCS,both,,,143.44,86.06,,107.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,107.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,30.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,107.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.39,114.75,
CARDIOMEDICAL SOFT TISSUE PATCH PTSF0611,2111034,CDM,278,RC,C1781,HCPCS,both,,,194.23,116.54,,145.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,145.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,41.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,145.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,122.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.8,155.38,
CATH CHOLANG OPERATIVE,2101158,CDM,278,RC,C1729,HCPCS,both,,,70.76,42.46,,53.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,53.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,15.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,53.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.5,56.61,
CATH PRUITT IRRIGATION OCCLUSION,2102709,CDM,278,RC,C2628,HCPCS,both,,,516.56,309.94,,387.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,387.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,335.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,111.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,413.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,325.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.84,413.25,
CAYENNE CROSS FIX KIT CM8000,2111424,CDM,278,RC,,,both,,,283.8,170.28,,212.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,212.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,184.47,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,61.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,212.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,178.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.15,227.04,
CAYENNE MENISCAL REPAIR DEVICE CM8002,2111425,CDM,278,RC,,,both,,,636.12,381.67,,477.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,477.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,413.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,136.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,400.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.34,508.9,
CAYENNE SCREW CM1725 1825,2111421,CDM,278,RC,,,both,,,685.02,411.01,,513.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,513.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,145.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,445.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,147.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,548.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,513.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,513.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,431.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.36,548.02,
CAYENNE SCREW KIT CM1500,2111423,CDM,278,RC,,,both,,,733.93,440.36,,550.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,550.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,477.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,157.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,587.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,550.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,462.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.38,587.14,
CAYENNE TIBIAL CANNULA 219377,2111422,CDM,278,RC,,,both,,,117.44,70.46,,88.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,88.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,25.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.95,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,88.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.06,93.95,
CONMED CANN THR NF 6MMX50MM,2109836,CDM,278,RC,C1713,HCPCS,both,,,110.33,66.2,,82.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,82.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,23.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.61,88.26,
CONMED CANN THR NF 8.4MMC50MM,2109837,CDM,278,RC,C1713,HCPCS,both,,,161.79,97.07,,121.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,121.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,34.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.15,129.43,
COOK FLOW INTRODUCER RYCFW-6.0-35-6-CB,2109466,CDM,278,RC,C1894,HCPCS,both,,,197.43,118.46,,148.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,148.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,42.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,124.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.45,157.94,
COOK HERNIA REPAIR GRAFT C-SAH-8P-13X15,2109081,CDM,278,RC,C1781,HCPCS,both,,,1533.64,920.18,,1150.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1150.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,326.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,996.87,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,329.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1226.91,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1150.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1150.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1150.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1150.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,966.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.24,1226.91,
COOK NESTER EMB COILS G26993,2109545,CDM,278,RC,C1760,HCPCS,both,,,621.9,373.14,,466.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,466.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,404.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,133.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.52,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,391.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,497.52,
COOK NESTER EMB COILS G26995,2109543,CDM,278,RC,C1760,HCPCS,both,,,621.9,373.14,,466.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,466.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,404.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,133.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.52,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,391.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.43,497.52,
COOK TORNADO EMB COIL G10416,2109631,CDM,278,RC,C1760,HCPCS,both,,,199.55,119.73,,149.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,149.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,42.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.89,159.64,
COOK TORNADO EMB COIL G10417,2109541,CDM,278,RC,C1760,HCPCS,both,,,651.61,390.97,,488.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,488.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.55,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,140.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,521.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,410.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.51,521.29,
COOK UNI STENT 6FX22 G49972,2111851,CDM,278,RC,C2617,HCPCS,both,,,317.95,190.77,,238.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,238.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,206.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,68.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,238.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,200.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.15,254.36,
COOK UNI STENT 6FX24 G49973,2111852,CDM,278,RC,C2617,HCPCS,both,,,317.95,190.77,,238.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,238.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,206.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,68.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,238.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,200.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.15,254.36,
COOK UNI STENT 6FX26 G49974,2111853,CDM,278,RC,C2617,HCPCS,both,,,347.49,208.49,,260.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,260.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.87,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,74.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.99,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,260.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,218.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.2,277.99,
COV MARLEX PLUG LG PNP8X3,2103067,CDM,278,RC,,,both,,,527.78,316.67,,395.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,395.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,343.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,113.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,395.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.14,422.22,
COV MARLEX PLUG MED PNP6X3,2103285,CDM,278,RC,C1781,HCPCS,both,,,590.08,354.05,,442.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,442.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,383.55,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,126.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,442.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,371.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.91,472.06,
COV MESH HERNIA PC015X,2112235,CDM,278,RC,,,both,,,1585.82,951.49,,1189.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1189.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,337.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1030.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,340.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1268.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1189.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1189.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1189.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1189.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,999.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.93,1268.66,
COV MESH HERNIA PCO12X,2112233,CDM,278,RC,,,both,,,1006.4,603.84,,754.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,754.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,214.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,216.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,805.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,754.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,634.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.21,805.12,
COV MESH HERNIA PCO2015X,2112274,CDM,278,RC,,,both,,,1798.35,1079.01,,1348.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1348.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,383.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1168.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,386.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1438.68,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1348.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1348.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1132.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.48,1438.68,
COV MESH HERNIA PCO3020X,2112275,CDM,278,RC,,,both,,,4058.11,2434.87,,3043.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3043.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,864.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,864.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2637.77,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,872.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3246.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3043.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3043.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3043.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3043.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2556.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.51,3246.49,
CR BARD COMPOSIX E/X MESH 10X13 0123113,2109568,CDM,278,RC,C1781,HCPCS,both,,,4177.3,2506.38,,3132.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3132.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,889.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,889.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2715.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,898.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3341.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3132.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3132.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3132.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3132.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2631.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.93,3341.84,
CR BARD COMPOSIX E/X MESH 6X8 0123680,2109565,CDM,278,RC,C1781,HCPCS,both,,,2077.24,1246.34,,1557.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1557.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,442.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,442.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1350.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,446.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1661.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1557.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1557.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,425.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1308.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,425.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,425.63,1661.79,
CR BARD COMPOSIX E/X MESH 7X9 0123790,2109566,CDM,278,RC,C1781,HCPCS,both,,,2753.35,1652.01,,2065.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2065.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,586.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,586.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1789.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,591.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2202.68,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2065.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2065.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2065.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2065.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1734.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.16,2202.68,
CR BARD COMPOSIX E/X MESH 8X10 0123810,2109567,CDM,278,RC,C1781,HCPCS,both,,,3538.1,2122.86,,2653.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2653.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,753.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,753.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2299.77,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,760.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2830.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2653.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2653.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2653.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2653.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2229,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.96,2830.48,
DAVOL KUGAL OVAL XLG 0010208,2109596,CDM,278,RC,C1781,HCPCS,both,,,3223.97,1934.38,,2417.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2417.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,686.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,686.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2095.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,693.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2579.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2417.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2417.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2417.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2417.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2031.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,660.59,2579.18,
DAVOL KUGAL PATCH 8CM OVAL 0010101,2111405,CDM,278,RC,C1781,HCPCS,both,,,731.03,438.62,,548.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,548.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,475.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,157.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,584.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,548.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,548.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,548.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,548.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,460.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.79,584.82,
DAVOL KUGAL PATCH LG CIRCLE 0010204,2109556,CDM,278,RC,C1781,HCPCS,both,,,1558.46,935.08,,1168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1168.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1013,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,335.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1246.77,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1168.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,981.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.33,1246.77,
DAVOL KUGAL PATCH M OVAL 0010105,2111364,CDM,278,RC,C1781,HCPCS,both,,,1073.61,644.17,,805.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,805.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,697.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,230.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,858.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,676.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.98,858.89,
DAVOL KUGAL PATCH MED 0010205,2109554,CDM,278,RC,,,both,,,1877.9,1126.74,,1408.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1408.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,399.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1220.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,403.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1502.32,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1408.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1408.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1408.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1408.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1183.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.78,1502.32,
DAVOL KUGAL PATCH MED CIRCLE 0010302,2109560,CDM,278,RC,,,both,,,1448.68,869.21,,1086.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1086.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,308.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,941.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,311.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1158.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1086.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1086.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,912.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.83,1158.94,
DAVOL KUGAL PATCH OVAL LG 0010202,2109595,CDM,278,RC,,,both,,,2381.08,1428.65,,1785.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1785.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,507.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,507.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1547.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,511.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1904.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1785.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1785.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1785.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1785.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1500.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.88,1904.86,
DAVOL KUGAL PATCH SM 0010211,2109553,CDM,278,RC,C1781,HCPCS,both,,,1301.83,781.1,,976.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,976.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,277.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,277.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,846.19,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,279.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1041.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,976.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,976.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,820.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.74,1041.46,
DAVOL KUGAL PATCH SM CIRCLE 0010203,2109555,CDM,278,RC,C1781,HCPCS,both,,,1130.6,678.36,,847.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,847.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,734.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,243.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,904.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,847.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,712.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.66,904.48,
DAVOL KUGAL PATCH SM CIRCLE 0010301,2109559,CDM,278,RC,C1781,HCPCS,both,,,1211.29,726.77,,908.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,908.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,787.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,260.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,969.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,908.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,908.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,908.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,908.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,763.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.19,969.03,
DAVOL KUGAL PATCH XLG OVAL 0010206,2109590,CDM,278,RC,C1781,HCPCS,both,,,3822,2293.2,,2866.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2866.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,814.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,814.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2484.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,821.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3057.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2866.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2866.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2866.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2866.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,783.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2407.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,783.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,783.13,3057.6,
DAVOL KUGAL PATCH XXLG 0010207,2109591,CDM,278,RC,C1781,HCPCS,both,,,5218.05,3130.83,,3913.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3913.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1111.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1111.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3391.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1121.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4174.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3913.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3913.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3913.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3913.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1069.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3287.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1069.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1069.18,4174.44,
DAVOL MARLEX PLUG SM,2103284,CDM,278,RC,,,both,,,474.64,284.78,,355.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,355.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,308.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,102.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,379.71,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,355.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,299.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.25,379.71,
DAVOL MARLEX PLUG XLG,2108437,CDM,278,RC,C1781,HCPCS,both,,,621.48,372.89,,466.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,466.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,403.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,133.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,391.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.34,497.18,
DAVOL MARLEX PLUG XXLG,2108763,CDM,278,RC,C1781,HCPCS,both,,,528.65,317.19,,396.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,396.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,343.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,113.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,422.92,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,396.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,333.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.32,422.92,
DAVOL SEPREMESH 6X8 1/2 5959680,2111962,CDM,278,RC,,,both,,,1092.51,655.51,,819.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,819.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,710.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,234.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,874.01,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,819.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,688.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.86,874.01,
DAVOL SEPREMESH 6X8 5959680,2111759,CDM,278,RC,,,both,,,1969.35,1181.61,,1477.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1477.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,419.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1280.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,423.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1575.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1477.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1477.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1477.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1477.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,403.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1240.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,403.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,403.52,1575.48,
DEP MITEK CAN FIX SCREW,2110779,CDM,278,RC,,,both,,,408.23,244.94,,306.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,306.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,265.35,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,87.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,306.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,257.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.65,326.58,
DEP MITEK MINI QUICKANCHOR 212035,2111818,CDM,278,RC,,,both,,,1010.93,606.56,,758.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,758.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,215.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,657.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,217.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,808.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,758.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,636.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.14,808.74,
DEP MITEK QUICKANCHOR 222984,2111525,CDM,278,RC,,,both,,,1271.75,763.05,,953.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,953.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,270.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,826.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,273.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1017.4,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,953.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,953.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,953.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,953.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,801.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.58,1017.4,
DEPUY ACETABULAR LINER,2113242,CDM,278,RC,C1776,HCPCS,both,,,9477.55,5686.53,,7108.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7108.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2018.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2018.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6160.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2037.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7582.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7108.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7108.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7108.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7108.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1941.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5970.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1941.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1941.95,7582.04,
DEPUY ACL KIT 232300,2110955,CDM,278,RC,,,both,,,732.24,439.34,,549.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,549.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,475.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,157.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,585.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,549.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,549.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,461.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.04,585.79,
DEPUY BUTTON/SPRING REPLACE 14599,2109819,CDM,278,RC,,,both,,,257.48,154.49,,193.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,193.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.36,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,55.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,193.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,162.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,205.98,
DEPUY CONSTRAINED LINER 1242-16-527,2112482,CDM,278,RC,C1776,HCPCS,both,,,9783.2,5869.92,,7337.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7337.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2083.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2083.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6359.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2103.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7826.56,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7337.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7337.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7337.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7337.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2004.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6163.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2004.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2004.58,7826.56,
DEPUY DYNAMIC LOCKING RING 1249-56-000,2112481,CDM,278,RC,C1776,HCPCS,both,,,1026.21,615.73,,769.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,769.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,218.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,667.04,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,220.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,820.97,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,769.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,769.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,646.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,210.27,820.97,
DEPUY FEMORAL HEAD 1365-30-000,2111714,CDM,278,RC,C1776,HCPCS,both,,,2460.76,1476.46,,1845.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1845.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,524.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1599.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,529.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1968.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1845.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1845.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1845.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1845.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1550.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.21,1968.61,
DEPUY FINGER PIP IMPLANT 1233-10-000,2112005,CDM,278,RC,L8630,HCPCS,both,,,1682.37,1009.42,,1261.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1261.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,358.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,358.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1093.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,361.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1345.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1261.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1059.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.72,1345.9,
DEPUY FINGER PIP IMPLANT 1233-20-000,2112006,CDM,278,RC,L8630,HCPCS,both,,,1682.37,1009.42,,1261.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1261.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,358.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,358.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1093.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,361.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1345.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1261.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1059.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.72,1345.9,
DEPUY HEALIX BR ANCHOR W/ORTHO 222233,2111732,CDM,278,RC,C1713,HCPCS,both,,,887.97,532.78,,665.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,665.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,577.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,190.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,710.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,665.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,665.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,559.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.95,710.38,
DEPUY IMPLANT COMPRESSION HIP SCREW,2109820,CDM,278,RC,C1713,HCPCS,both,,,257.48,154.49,,193.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,193.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.36,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,55.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,193.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,162.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.76,205.98,
DEPUY KEYLESS LAG SCREW STERILS HIP,2109823,CDM,278,RC,C1713,HCPCS,both,,,561.96,337.18,,421.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,421.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,365.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,120.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.57,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,421.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,354.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.15,449.57,
DEPUY MEDIAL PILON PLATE LOWER EXT,2109800,CDM,278,RC,C1713,HCPCS,both,,,694.36,416.62,,520.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,520.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,147.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,451.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,149.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,520.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,437.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.27,555.49,
DEPUY MOD CEM STEM 86-6402,2111744,CDM,278,RC,C1776,HCPCS,both,,,3060.8,1836.48,,2295.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2295.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,651.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,651.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1989.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,658.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2448.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2295.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2295.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2295.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2295.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1928.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,627.16,2448.64,
DEPUY NINETY LOCK,2109936,CDM,278,RC,,,both,,,186.82,112.09,,140.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,140.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.43,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,40.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,140.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,117.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.28,149.46,
DEPUY PROX HUM PLATE UPPER EXT,2109801,CDM,278,RC,C1713,HCPCS,both,,,628.16,376.9,,471.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,471.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,408.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,135.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.53,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,471.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.71,502.53,
DEPUY PROXIMAL HUMERUS PLATE 4 HOLESSPL4,2109934,CDM,278,RC,C1713,HCPCS,both,,,2537.67,1522.6,,1903.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1903.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1649.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,545.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2030.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1903.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1598.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.97,2030.14,
DEPUY REV CEM TRAY 1294-35-125/130,2111745,CDM,278,RC,C1776,HCPCS,both,,,14688.58,8813.15,,11016.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,11016.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3128.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3128.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9547.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,3158.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11750.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,11016.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11016.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11016.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11016.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3009.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9253.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3009.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3009.69,11750.86,
DEPUY ROT PLAT STAB LIB INSERT 96-2127,2111747,CDM,278,RC,C1776,HCPCS,both,,,5249.55,3149.73,,3937.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3937.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1118.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1118.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3412.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1128.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4199.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3937.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3937.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3937.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3937.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3307.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.63,4199.64,
DEPUY ROT PLAT STAB TIB INSERT 96-2151,2111658,CDM,278,RC,C1776,HCPCS,both,,,5100.91,3060.55,,3825.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3825.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1086.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1086.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3315.59,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1096.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4080.73,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3825.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3825.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3825.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3825.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1045.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3213.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1045.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1045.18,4080.73,
DEPUY S COUPLE T SMALL FRAG,2109784,CDM,278,RC,C1713,HCPCS,both,,,635.16,381.1,,476.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,476.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,412.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,136.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.13,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,476.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,400.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,508.13,
DEPUY SOLID TAP,2109844,CDM,278,RC,C1713,HCPCS,both,,,220.67,132.4,,165.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,165.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,47.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,176.54,
DEPUY STD PEG,2109935,CDM,278,RC,,,both,,,105.87,63.52,,79.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,79.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,22.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.69,84.7,
DEPUY SUPRACONDYLAR PLATE STERILE HIP SC,2109822,CDM,278,RC,C1713,HCPCS,both,,,1434.34,860.6,,1075.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1075.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,305.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,932.32,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,308.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1147.47,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1075.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1075.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,903.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.9,1147.47,
DEPUY SYNTHESE FEMORAL HEAD,2112843,CDM,278,RC,C1776,HCPCS,both,,,3404.12,2042.47,,2553.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2553.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,725.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,725.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2212.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,731.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2723.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2553.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2553.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2553.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2553.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,697.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2144.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,697.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,697.5,2723.3,
DEPUY VOLAR DISTAL RADIUS PLATE UPPER EX,2109803,CDM,278,RC,C1713,HCPCS,both,,,494.48,296.69,,370.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,370.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,321.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,106.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,395.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,370.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,311.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.32,395.58,
DRILL BIT 1.5MM MINI FRAG,2113034,CDM,278,RC,,,both,,,133.87,80.32,,100.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,100.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,28.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,100.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.43,107.1,
DRILL BIT 2.7MM MINI FRAG,2113035,CDM,278,RC,,,both,,,133.87,80.32,,100.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,100.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,28.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,100.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.43,107.1,
DUAL MESH 1DLME03,2109272,CDM,278,RC,C1781,HCPCS,both,,,1092.3,655.38,,819.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,819.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,710,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,234.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,873.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,819.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,688.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.81,873.84,
DUAL MESH 1DLME04,2109273,CDM,278,RC,C1781,HCPCS,both,,,1986,1191.6,,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1290.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,426.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1588.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1251.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,1588.8,
DUAL MESH PLUS 10X15 1DLMCP03,2108894,CDM,278,RC,C1781,HCPCS,both,,,1037.34,622.4,,778.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,778.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,674.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,223.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,829.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,778.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,778.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,778.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,778.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,653.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.55,829.87,
DUAL MESH PLUS 1DLMCP05,2109132,CDM,278,RC,C1781,HCPCS,both,,,1146.27,687.76,,859.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,859.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,244.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,745.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,246.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,917.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,859.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,859.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,859.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,859.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,722.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.87,917.02,
DUAL MESH PLUS 1DLMCP06,2109127,CDM,278,RC,C1781,HCPCS,both,,,2553.16,1531.9,,1914.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1914.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,543.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1659.55,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,548.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2042.53,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1914.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1914.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1608.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.14,2042.53,
DUAL MESH PLUS 1DLMCP07,2109128,CDM,278,RC,C1781,HCPCS,both,,,4610.49,2766.29,,3457.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3457.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,982.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,982.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2996.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,991.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3688.39,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3457.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3457.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3457.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3457.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,944.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2904.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,944.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,944.69,3688.39,
ESSURE TUBAL KIT ESS205,2110748,CDM,278,RC,,,both,,,2866.55,1719.93,,2149.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2149.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,610.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1863.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,616.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2293.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2149.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2149.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,587.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1805.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,587.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,587.36,2293.24,
GORTEX DUAL MESH 10CMX15CMX1MM,2108395,CDM,278,RC,C1781,HCPCS,both,,,1177.07,706.24,,882.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,882.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,250.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,765.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,253.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,941.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,882.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,882.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,882.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,882.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,741.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.18,941.66,
GORTEX DUAL MESH 15CMX19CMX1MM,2108396,CDM,278,RC,C1781,HCPCS,both,,,2183.44,1310.06,,1637.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1637.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,465.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1419.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,469.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1746.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1637.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1637.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1637.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1637.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,447.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1375.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,447.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,447.39,1746.75,
GORTEX DUAL MESH 18CMX24CMX1MM,2108397,CDM,278,RC,C1781,HCPCS,both,,,3394.66,2036.8,,2546,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2546,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,723.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,723.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2206.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,729.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2715.73,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,695.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2138.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,695.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,695.57,2715.73,
GORTEX DUAL MESH 20CMX30CMX1MM,2108398,CDM,278,RC,C1781,HCPCS,both,,,4708.06,2824.84,,3531.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3531.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1002.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1002.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3060.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1012.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3766.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3531.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3531.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3531.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3531.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2966.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.68,3766.45,
GORTEX GRAFT 4-7 70CM TAPERED FLEX,2102909,CDM,278,RC,C1768,HCPCS,both,,,3072.69,1843.61,,2304.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2304.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1997.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2458.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2304.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1935.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.59,2458.15,
GORTEX GRAFT 4-7MM 45CM RI,2102338,CDM,278,RC,C1768,HCPCS,both,,,2693.94,1616.36,,2020.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2020.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,573.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,573.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1751.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,579.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2155.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2020.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2020.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2020.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2020.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,551.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1697.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,551.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,551.99,2155.15,
GORTEX GRAFT 4-7X40CM,2103055,CDM,278,RC,C1768,HCPCS,both,,,5516.68,3310.01,,4137.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4137.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1175.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1175.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3585.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1186.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4413.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4137.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4137.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4137.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4137.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1130.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3475.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1130.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1130.37,4413.34,
GORTEX GRAFT 4-7X45CM,2103056,CDM,278,RC,C1786,HCPCS,both,,,181.09,108.65,,135.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,135.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,38.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,135.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.11,144.87,
GORTEX GRAFT 4-7XCM,2109516,CDM,278,RC,C1768,HCPCS,both,,,1147.47,688.48,,860.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,860.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,244.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,745.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,246.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,917.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,860.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,722.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.12,917.98,
GORTEX GRAFT 6MM-70CM,2102931,CDM,278,RC,C1768,HCPCS,both,,,2266.4,1359.84,,1699.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1699.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,482.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1473.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,487.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1813.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1699.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1699.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1699.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1699.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.39,1813.12,
GORTEX VIABAHN ENDOPROSTHESIS VBH061502,2110965,CDM,278,RC,C1874,HCPCS,both,,,6754.53,4052.72,,5065.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5065.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1438.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1438.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4390.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1452.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5403.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5065.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5065.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5065.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5065.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1384,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4255.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1384,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1384,5403.62,
GRAFT AC,2112167,CDM,278,RC,C1762,HCPCS,both,,,2426.38,1455.83,,1819.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1819.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,516.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,516.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1577.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,521.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1941.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1819.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1819.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1819.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1819.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1528.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.17,1941.1,
GRAFT ACL POS TIB TENDON,2111519,CDM,278,RC,C1762,HCPCS,both,,,5023.27,3013.96,,3767.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3767.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1069.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1069.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3265.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1080,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4018.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3767.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3767.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3767.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3767.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1029.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3164.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1029.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1029.27,4018.62,
GRAFT ACL POS TIB TENDON,2112775,CDM,278,RC,C1762,HCPCS,both,,,3991.64,2394.98,,2993.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2993.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,850.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2594.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,858.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3193.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2993.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2993.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2993.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2993.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,817.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2514.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,817.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,817.89,3193.31,
GRAFT BIOCLEANSE GRACILLIS TENDONSTRYKER,2112827,CDM,278,RC,C1762,HCPCS,both,,,2231.63,1338.98,,1673.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1673.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,475.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,475.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1450.56,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,479.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1785.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1673.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1673.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,457.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1405.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,457.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,457.26,1785.3,
GRAFT BIOCORTICAL EVANS 12MM,2112890,CDM,278,RC,C1762,HCPCS,both,,,3939.28,2363.57,,2954.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2954.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,839.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,839.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2560.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,846.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3151.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2954.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2954.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2954.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2954.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,807.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2481.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,807.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,807.16,3151.42,
GRAFT FEMORAL HEAD W/O CARTI 620100,2111898,CDM,278,RC,C1762,HCPCS,both,,,3310.97,1986.58,,2483.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2483.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,705.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,705.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2152.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,711.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2648.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2483.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2483.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2483.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2483.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,678.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2085.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,678.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,678.42,2648.78,
GRAFT GRACILIS TENDON,2112434,CDM,278,RC,C1762,HCPCS,both,,,4511.05,2706.63,,3383.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3383.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,960.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2932.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,969.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3608.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3383.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2841.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.31,3608.84,
GRAFT ILIAC CREST BONE TRICORTI PICW2,2112421,CDM,278,RC,C1762,HCPCS,both,,,1619.15,971.49,,1214.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1214.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,344.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1052.45,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,348.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1295.32,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1214.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1214.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1214.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1214.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1020.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.76,1295.32,
GRAFT ILIAC CREST BONE TRICORTI PRESOVON,2112219,CDM,278,RC,C1762,HCPCS,both,,,2625.28,1575.17,,1968.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1968.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,559.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,559.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1706.43,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,564.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2100.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1968.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1968.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1968.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1968.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1653.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.92,2100.22,
GRAFT MATRIX HD 10X10,2112816,CDM,278,RC,C1762,HCPCS,both,,,6582.31,3949.39,,4936.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4936.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1402.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1402.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4278.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1415.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5265.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4936.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4936.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4936.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4936.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4146.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1348.72,5265.85,
GRAFT MATRIX HD 4X6,2113068,CDM,278,RC,C1762,HCPCS,both,,,2438.15,1462.89,,1828.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1828.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,519.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1584.8,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,524.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950.52,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1828.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1828.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1828.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1828.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1536.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.58,1950.52,
GRAFT MATRIX HD 5CMX8CM,2113036,CDM,278,RC,C1762,HCPCS,both,,,5613.61,3368.17,,4210.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4210.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1195.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1195.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3648.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1206.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4490.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4210.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4210.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4210.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4210.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3536.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1150.23,4490.89,
GRAFT SEMI T 453015,2112841,CDM,278,RC,C1762,HCPCS,both,,,2637.3,1582.38,,1977.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1977.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,561.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,561.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1714.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,567.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2109.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1977.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1977.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1977.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1977.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1661.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.38,2109.84,
GRAFT STRUT 6 FEMOR PLATE 25A001,2111866,CDM,278,RC,C1713,HCPCS,both,,,2197.75,1318.65,,1648.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1648.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,468.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1428.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,472.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1758.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1648.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1648.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1384.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450.32,1758.2,
GRAFT STRUT FEMORAL CORTICAL 400610,2111668,CDM,278,RC,C1762,HCPCS,both,,,957.78,574.67,,718.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,718.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,204.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,622.56,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,205.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,766.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,718.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,603.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.25,766.22,
GRAFT STRUT WHOLE BONE 25A005,2112163,CDM,278,RC,C1762,HCPCS,both,,,2438.42,1463.05,,1828.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1828.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,519.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1584.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,524.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1950.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1828.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1828.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1828.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1828.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1536.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.63,1950.74,
GROSHONG CATH BARD 9.5 PEEL A PART,2103155,CDM,278,RC,C1751,HCPCS,both,,,1269.37,761.62,,952.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,952.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,270.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,270.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,825.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,272.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1015.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,952.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,799.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.09,1015.5,
GROSHONG CATH BARD INTRO EZE 9.5 DUAL L,2103787,CDM,278,RC,C1751,HCPCS,both,,,1126.57,675.94,,844.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,844.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,732.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,242.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,901.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,844.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,844.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,844.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,844.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,709.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.83,901.26,
GUIDE PIN BAYONET POINT,2109845,CDM,278,RC,C1713,HCPCS,both,,,220.67,132.4,,165.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,165.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,47.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,176.54,
HORNET INSERT BIOSTINGER IMPLANT 10MM,2109738,CDM,278,RC,,,both,,,292.81,175.69,,219.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,219.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,190.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,62.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,219.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,184.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60,234.25,
HORNET INSERT BIOSTINGER IMPLANT 13MM,2109737,CDM,278,RC,,,both,,,223.95,134.37,,167.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,167.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,145.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,167.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.89,179.16,
INTEGRA ARTHROPLASTY INPLANT,2112207,CDM,278,RC,C1776,HCPCS,both,,,2799.61,1679.77,,2099.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2099.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,596.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,596.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1819.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,601.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2239.69,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2099.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2099.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2099.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2099.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,573.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1763.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,573.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,573.64,2239.69,
INTEGRA ARTHROPLASTY INPLANT,2112388,CDM,278,RC,C1776,HCPCS,both,,,2826.45,1695.87,,2119.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2119.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,602.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,602.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1837.19,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,607.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2261.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2119.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2119.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2119.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2119.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,579.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1780.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,579.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,579.14,2261.16,
INTEGRA CANNULATED RELIEF DRILL AI4030,2112619,CDM,278,RC,,,both,,,566.74,340.04,,425.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,425.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,368.38,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,121.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,453.39,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,425.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,357.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.13,453.39,
INTEGRA HEADLESS SCREW AH2522/2514/2512,2112620,CDM,278,RC,C1713,HCPCS,both,,,778.18,466.91,,583.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,583.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,505.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,167.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,622.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,583.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,583.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,583.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,583.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,490.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.45,622.54,
INTREGRA K WIRE SMOOTH DOUBLE POI AW111,2112617,CDM,278,RC,C1713,HCPCS,both,,,181.31,108.79,,135.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,135.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,38.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,135.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.15,145.05,
MARLEX MESH 10X14,2103282,CDM,278,RC,C1781,HCPCS,both,,,659.14,395.48,,494.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,494.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,428.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,141.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,494.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,415.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.06,527.31,
MARLEX MESH 2X4,2103281,CDM,278,RC,C1781,HCPCS,both,,,304.48,182.69,,228.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,228.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.91,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,65.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,228.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,191.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.39,243.58,
MARLEX MESH 3X6,2103788,CDM,278,RC,C1781,HCPCS,both,,,1064.51,638.71,,798.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,798.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,691.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,228.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,851.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,798.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,798.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,670.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.12,851.61,
MARLEX MESH 6X6,2103283,CDM,278,RC,C1781,HCPCS,both,,,394.02,236.41,,295.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,295.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.11,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,84.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,295.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,248.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.73,315.22,
MEDTRONIC BONE PUTTY 1CC GRAFT TISSUE,2111671,CDM,278,RC,,,both,,,547.18,328.31,,410.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,410.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,355.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,117.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,410.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,344.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.12,437.74,
MEDTRONIC BONE PUTTY 2CC GRAFT TISSUE,2113111,CDM,278,RC,,,both,,,547.18,328.31,,410.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,410.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,355.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,117.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,410.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,344.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.12,437.74,
MEDTRONIC BONE PUTTY 5CC T43105,2111495,CDM,278,RC,,,both,,,1914.73,1148.84,,1436.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1436.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,407.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1244.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,411.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1531.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1436.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1436.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1436.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1436.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1206.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.33,1531.78,
MEDTRONIC HTO WEDGE 72MM,2113121,CDM,278,RC,,,both,,,2103.5,1262.1,,1577.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1577.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,448.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,448.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1367.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,452.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1682.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1577.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1577.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1577.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1577.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,431.01,1682.8,
OSTEO REMEDIES ACETABULAR CUP,2112902,CDM,278,RC,C1776,HCPCS,both,,,2363.57,1418.14,,1772.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1772.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,503.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1536.32,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,508.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1890.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1772.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1772.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1772.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1772.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1489.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.3,1890.86,
OSTEOBOOST 10CC,2113210,CDM,278,RC,,,both,,,4641.44,2784.86,,3481.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3481.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,988.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,988.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3016.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,997.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3713.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3481.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3481.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3481.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3481.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,951.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2924.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,951.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,951.03,3713.15,
OSTEOREMEDIES FEMORAL COMP,2112762,CDM,278,RC,C1776,HCPCS,both,,,4701.47,2820.88,,3526.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3526.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3761.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,3761.18,
OSTEOREMEDIES FEMORAL HEAD,2112901,CDM,278,RC,C1776,HCPCS,both,,,4701.47,2820.88,,3526.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3526.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3761.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,3761.18,
OSTEOREMEDIES FEMORAL LONG STEM HEAD,2113248,CDM,278,RC,C1776,HCPCS,both,,,5407.5,3244.5,,4055.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4055.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1151.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1151.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3514.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1162.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4326,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4055.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4055.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4055.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4055.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1108,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3406.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1108,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1108,4326,
OSTEOREMEDIES MODULAR LONG STEM,2113203,CDM,278,RC,C1776,HCPCS,both,,,4701.47,2820.88,,3526.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3526.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3761.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,3761.18,
OSTEOREMEDIES TIBIAL COMPONENT RKTBLG,2112763,CDM,278,RC,C1776,HCPCS,both,,,4701.47,2820.88,,3526.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3526.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3761.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.33,3761.18,
PACEMAKER TEMPORARY LEAD INT HLS1007M,2108988,CDM,278,RC,C1898,HCPCS,both,,,560.47,336.28,,420.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,420.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,364.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,120.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,448.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,420.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,353.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.84,448.38,
PICC 4F HIGH FLOW SINGLE LUMEN 3194108D,2112266,CDM,278,RC,C1751,HCPCS,both,,,380,228,,285,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,285,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,247,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,81.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.86,304,
PICC 5F HIGH FLOW DUAL LUMEN 3295108D,2112265,CDM,278,RC,C1751,HCPCS,both,,,396.46,237.88,,297.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,297.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,257.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,85.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,297.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,249.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.23,317.17,
PICC 5F HIGH FLOW TRIPLE LUMEN 3395108QD,2112264,CDM,278,RC,C1751,HCPCS,both,,,487.91,292.75,,365.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,365.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,317.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,104.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.33,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,365.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,307.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.97,390.33,
PICC L CATH NEONATAL 28PIC25,2103422,CDM,278,RC,C1751,HCPCS,both,,,638.7,383.22,,479.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,479.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,415.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,137.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,510.96,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,479.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,402.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.87,510.96,
PICC L CATH PED 24PIC30,2103423,CDM,278,RC,C1751,HCPCS,both,,,584.56,350.74,,438.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,438.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,379.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,125.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,467.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,438.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,368.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.78,467.65,
POWERGLIDE CATH ONLY 10CM M20100,2112262,CDM,278,RC,C1751,HCPCS,both,,,202.63,121.58,,151.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,151.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,43.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,151.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.52,162.1,
POWERGLIDE CATH ONLY 8CM M20080,2112261,CDM,278,RC,C1751,HCPCS,both,,,202.63,121.58,,151.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,151.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,43.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,151.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.52,162.1,
POWERGLIDE TRAY 10CM M020101,2112260,CDM,278,RC,C1751,HCPCS,both,,,173.88,104.33,,130.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,130.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,37.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,139.1,
POWERGLIDE TRAY 8CM M020081,2112259,CDM,278,RC,C1751,HCPCS,both,,,173.88,104.33,,130.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,130.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,37.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.63,139.1,
PROLENE MESH 3X6 PMII,2101525,CDM,278,RC,C1781,HCPCS,both,,,436.28,261.77,,327.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,327.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,283.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,93.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,327.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,274.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.39,349.02,
RETROGRADE KNIFE 4449,2110590,CDM,278,RC,,,both,,,106.19,63.71,,79.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,79.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,22.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.95,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,79.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.76,84.95,
RTI BIOADAPT FOAM MEDIUM 6CC,2113072,CDM,278,RC,C1762,HCPCS,both,,,1625.43,975.26,,1219.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1219.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,346.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1056.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,349.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1300.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1219.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1219.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1219.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1219.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1024.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.05,1300.34,
RTI LLIUM STRIP TRICORTICAL,2113241,CDM,278,RC,C1762,HCPCS,both,,,3244.5,1946.7,,2433.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2433.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,691.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2108.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,697.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2595.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2433.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2433.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2433.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2433.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,664.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2044.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,664.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,664.8,2595.6,
RTI TRI CORT GRAFT D03114 14X15MM,2112727,CDM,278,RC,C1762,HCPCS,both,,,1206.1,723.66,,904.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,904.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,783.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,259.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,759.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,964.88,
RTI TRI CORT GRAFT DO3108 8X15MM,2112725,CDM,278,RC,C1762,HCPCS,both,,,1206.1,723.66,,904.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,904.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,783.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,259.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,759.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,964.88,
RTI TRI CORTI GRAFT 12x15mm DO3112,2112726,CDM,278,RC,C1762,HCPCS,both,,,1206.1,723.66,,904.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,904.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,783.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,259.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,759.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.13,964.88,
S&N #13 FEMORAL COMPONENT 71309013,2110713,CDM,278,RC,C1776,HCPCS,both,,,10170.11,6102.07,,7627.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7627.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2166.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2166.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6610.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2186.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8136.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7627.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7627.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7627.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7627.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2083.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6407.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2083.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2083.86,8136.09,
S&N 15MM INSERT 71420784,2109891,CDM,278,RC,C1713,HCPCS,both,,,1605.04,963.02,,1203.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1203.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,341.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,341.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1043.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,345.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1284.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1203.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1203.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,328.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1011.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,328.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,328.87,1284.03,
S&N 20 DEGREE LINER 71333323,2109950,CDM,278,RC,,,both,,,5021.14,3012.68,,3765.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3765.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1069.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1069.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3263.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1079.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4016.91,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3765.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3765.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3765.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3765.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1028.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3163.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1028.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1028.83,4016.91,
S&N 3.2 GUIDE PIN 71110500,2110895,CDM,278,RC,,,both,,,70.86,42.52,,53.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,53.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,15.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.69,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,53.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,44.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.52,56.69,
S&N 32MM ACETABULAR LINER 71333335,2110712,CDM,278,RC,C1776,HCPCS,both,,,3277.02,1966.21,,2457.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2457.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,698.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2130.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,704.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2621.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2457.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2457.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2457.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2457.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2064.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671.46,2621.62,
S&N 32MM FEMORAL HEAD 71343200,2110714,CDM,278,RC,C1776,HCPCS,both,,,4482.94,2689.76,,3362.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3362.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,954.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,954.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2913.91,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,963.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3586.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3362.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3362.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3362.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3362.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,918.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2824.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,918.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,918.55,3586.35,
S&N 32MM PATELLER 71420576,2109892,CDM,278,RC,C1776,HCPCS,both,,,14693.25,8815.95,,11019.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,11019.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3129.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3129.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9550.61,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,3159.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11754.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,11019.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11019.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11019.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11019.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3010.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9256.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3010.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3010.65,11754.6,
S&N 4.5 NON LOCKING SCREW,2110878,CDM,278,RC,,,both,,,91.88,55.13,,68.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,68.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.72,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,19.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,68.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.83,73.5,
S&N 46 ACET SHELL 71336446,2109949,CDM,278,RC,,,both,,,4898.92,2939.35,,3674.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3674.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1043.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3184.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1053.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3919.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3674.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3674.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3674.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3674.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1003.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3086.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1003.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1003.79,3919.14,
S&N 5 HOLE PLATE,2112896,CDM,278,RC,C1713,HCPCS,both,,,180.02,108.01,,135.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,135.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,38.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.89,144.02,
S&N 60/65MM LOCKING SCREW,2110880,CDM,278,RC,,,both,,,403.88,242.33,,302.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,302.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,262.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,86.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,323.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,302.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,254.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.76,323.1,
S&N 7.0 CANN SCREW 90MM 71107090,2110894,CDM,278,RC,,,both,,,425.32,255.19,,318.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,318.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,276.46,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,91.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,318.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,267.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,340.26,
S&N 71683140L,2110303,CDM,278,RC,C1776,HCPCS,both,,,5119.58,3071.75,,3839.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3839.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1090.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1090.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3327.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1100.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4095.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3839.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3839.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3839.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3839.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1049,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3225.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1049,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1049,4095.66,
S&N 71751147,2110483,CDM,278,RC,,,both,,,335.46,201.28,,251.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,251.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,218.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,72.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,268.37,
S&N BIPOLAR 71322045,2109899,CDM,278,RC,,,both,,,2923.1,1753.86,,2192.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2192.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,622.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,622.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1900.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,628.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2338.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2192.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2192.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2192.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2192.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1841.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,598.94,2338.48,
S&N BONE SCREW 71332525,2109951,CDM,278,RC,C1713,HCPCS,both,,,339.81,203.89,,254.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,254.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,73.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,254.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,214.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.63,271.85,
S&N CANCELLOUS SCREW 71755040,2110475,CDM,278,RC,,,both,,,430.3,258.18,,322.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,322.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,279.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,92.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,322.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,271.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.17,344.24,
S&N CAPTURED SCREW 71681236,2110545,CDM,278,RC,,,both,,,316.15,189.69,,237.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,237.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,67.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.92,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,199.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.78,252.92,
S&N COMP SCREW 71683945,2110304,CDM,278,RC,,,both,,,340.97,204.58,,255.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,255.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,221.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,73.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,255.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,214.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.86,272.78,
S&N CORT SCREW 2.0,2112898,CDM,278,RC,C1713,HCPCS,both,,,150.52,90.31,,112.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,112.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,32.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,120.42,
S&N CORTICAL SCREW 71754022,2110478,CDM,278,RC,,,both,,,353.06,211.84,,264.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,264.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,75.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,222.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.34,282.45,
S&N CORTICAL SCREW 7182,2110911,CDM,278,RC,,,both,,,98.98,59.39,,74.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,74.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,21.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,74.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.28,79.18,
S&N FEM LINER 54MM 71336454,2110710,CDM,278,RC,C1776,HCPCS,both,,,3674.11,2204.47,,2755.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2755.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,782.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,782.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2388.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,789.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2939.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2755.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2755.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2755.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2755.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,752.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2314.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,752.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,752.83,2939.29,
S&N FEMORAL 4L 7140006,2109964,CDM,278,RC,C1776,HCPCS,both,,,7282.12,4369.27,,5461.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5461.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1551.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1551.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4733.38,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1565.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5825.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5461.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5461.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5461.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5461.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1492.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4587.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1492.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1492.11,5825.7,
S&N FEMORAL COMP 71420022,2110323,CDM,278,RC,,,both,,,6553.92,3932.35,,4915.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4915.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1395.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1395.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4260.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1409.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5243.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4915.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1342.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4128.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1342.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1342.9,5243.14,
S&N FEMORAL HEAD 71302200,2109940,CDM,278,RC,C1776,HCPCS,both,,,2459.7,1475.82,,1844.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1844.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,523.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1598.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,528.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1967.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1844.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1844.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1844.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1844.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1549.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.99,1967.76,
S&N FEMORAL HEAD 71302803,2109898,CDM,278,RC,C1776,HCPCS,both,,,1205.6,723.36,,904.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,904.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,783.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,259.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,904.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,904.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,759.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.03,964.48,
S&N FEMORAL HEAD 71420026/71420024,2109889,CDM,278,RC,C1776,HCPCS,both,,,5461.62,3276.97,,4096.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4096.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1163.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1163.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3550.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1174.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4369.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4096.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4096.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4096.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4096.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1119.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3440.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1119.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1119.09,4369.3,
S&N FEMORAL HEAD+0 71302800,2109948,CDM,278,RC,C1776,HCPCS,both,,,2459.7,1475.82,,1844.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1844.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,523.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1598.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,528.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1967.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1844.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1844.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1844.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1844.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1549.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.99,1967.76,
S&N FEMORAL STEM 71309012,2109939,CDM,278,RC,C1776,HCPCS,both,,,13559.47,8135.68,,10169.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,10169.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2888.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2888.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8813.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2915.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10847.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,10169.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10169.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10169.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10169.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2778.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8542.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2778.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2778.34,10847.58,
S&N FEMORAL SYSTEM 71309010,2109897,CDM,278,RC,C1776,HCPCS,both,,,8358.61,5015.17,,6268.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,6268.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1780.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1780.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5433.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1797.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6686.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,6268.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6268.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6268.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6268.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1712.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5265.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1712.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1712.68,6686.89,
S&N GEN DISHED ART INSERT 71420790,2112008,CDM,278,RC,C1776,HCPCS,both,,,3448.46,2069.08,,2586.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2586.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,734.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,734.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2241.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,741.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2758.77,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2586.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2586.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2586.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2586.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2172.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.59,2758.77,
S&N GRADUATED DRILL 71063006,2110893,CDM,278,RC,,,both,,,283.04,169.82,,212.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,212.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,60.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,212.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,178.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,226.43,
S&N GUIDE WIRE 71631690,2110481,CDM,278,RC,,,both,,,198.81,119.29,,149.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,149.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,42.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,149.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.74,159.05,
S&N GUIDE WIRE 71687000,2109946,CDM,278,RC,,,both,,,98.34,59,,73.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,73.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,21.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.67,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.15,78.67,
S&N HEAD SCREW 25MM 71332525,2110711,CDM,278,RC,,,both,,,254.94,152.96,,191.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,191.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,54.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.95,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,191.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,160.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.24,203.95,
S&N HUM NAIL 71770816,2110480,CDM,278,RC,C1713,HCPCS,both,,,2813.51,1688.11,,2110.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2110.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,599.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,599.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1828.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,604.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2250.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2110.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2110.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2110.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2110.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1772.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576.49,2250.81,
S&N HUM NAIL 71770924,2110476,CDM,278,RC,,,both,,,2813.51,1688.11,,2110.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2110.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,599.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,599.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1828.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,604.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2250.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2110.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2110.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2110.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2110.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1772.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,576.49,2250.81,
S&N INSERT 13MM,2109966,CDM,278,RC,,,both,,,2308.73,1385.24,,1731.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1731.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,491.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1500.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,496.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1846.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1731.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1731.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1731.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1731.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,473.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1454.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,473.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,473.06,1846.98,
S&N INSERT 9MM 71420766,2110326,CDM,278,RC,,,both,,,2770.55,1662.33,,2077.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2077.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,590.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,590.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1800.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,595.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2216.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2077.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2077.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2077.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2077.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1745.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.69,2216.44,
S&N JET X STD CENTRAL BODY 71051042,2110890,CDM,278,RC,,,both,,,3641.01,2184.61,,2730.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2730.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,775.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,775.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2366.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,782.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2912.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2730.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2730.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2730.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2730.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2293.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.04,2912.81,
S&N JET X TRANS ANKLE CLAMP 71051054,2110892,CDM,278,RC,,,both,,,4096.13,2457.68,,3072.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3072.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,872.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,872.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2662.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,880.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3276.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3072.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3072.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3072.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3072.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,839.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2580.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,839.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,839.3,3276.9,
S&N K WIRE,2110897,CDM,278,RC,,,both,,,88.48,53.09,,66.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,66.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,19.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,66.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,55.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.13,70.78,
S&N K WIRE 7116,2110541,CDM,278,RC,,,both,,,165.92,99.55,,124.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,124.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,124.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,104.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34,132.74,
S&N KNEE NAIL 71633420,2110398,CDM,278,RC,C1713,HCPCS,both,,,3850.75,2310.45,,2888.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2888.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,820.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,820.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2502.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,827.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3080.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2888.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2888.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2888.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2888.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2425.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.02,3080.6,
S&N LAG SCREW 121106,2109944,CDM,278,RC,C1713,HCPCS,both,,,433.59,260.15,,325.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,325.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,281.83,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,93.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,325.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,273.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.84,346.87,
S&N LAG SCREW 71684120,2110544,CDM,278,RC,,,both,,,1008.49,605.09,,756.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,756.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,214.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,655.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,216.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,806.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,756.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,756.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,756.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,756.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,635.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.64,806.79,
S&N LG FROG DRILL 71173505,2110877,CDM,278,RC,,,both,,,157.55,94.53,,118.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,118.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,33.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,118.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,99.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.28,126.04,
S&N LOCKING SCREW,2110879,CDM,278,RC,,,both,,,203.59,122.15,,152.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,152.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,43.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,152.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.72,162.87,
S&N LOCKING SCREW 5182.2310,2110539,CDM,278,RC,,,both,,,229.47,137.68,,172.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,172.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,49.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,172.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,144.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.02,183.58,
S&N LOCKING SCREW 7182-2322,2110537,CDM,278,RC,,,both,,,610.12,366.07,,457.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,457.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,396.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,131.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,457.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,457.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,384.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.01,488.1,
S&N LONG PILOT DRILL 4.0 71631110,2109868,CDM,278,RC,,,both,,,350.84,210.5,,263.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,263.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,75.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.67,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,263.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,221.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.89,280.67,
S&N NAFL 130 DEGREE 71647444,2109871,CDM,278,RC,,,both,,,4325.19,2595.11,,3243.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3243.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,921.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,921.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2811.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,929.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3460.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3243.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3243.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3243.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3243.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,886.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2724.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,886.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,886.23,3460.15,
S&N NAFL L TAN 71637440,2109942,CDM,278,RC,C1713,HCPCS,both,,,5813.95,3488.37,,4360.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4360.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1238.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1238.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3779.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1250,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4651.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4360.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4360.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4360.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4360.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1191.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3662.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1191.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1191.28,4651.16,
S&N NAIL 71648236,2110917,CDM,278,RC,,,both,,,3574.91,2144.95,,2681.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2681.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,761.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,761.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2323.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,768.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2859.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2681.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2252.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.5,2859.93,
S&N NAIL 71683012R,2109945,CDM,278,RC,C1713,HCPCS,both,,,1908.78,1145.27,,1431.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1431.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,406.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1240.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,410.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1527.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1431.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1431.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1431.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1431.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1202.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.11,1527.02,
S&N NAIL 71683014R,2110813,CDM,278,RC,,,both,,,1908.78,1145.27,,1431.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1431.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,406.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1240.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,410.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1527.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1431.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1431.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1431.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1431.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1202.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.11,1527.02,
S&N NL SCREW,2110898,CDM,278,RC,,,both,,,154.47,92.68,,115.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,115.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,33.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.65,123.58,
S&N OFF SET CLAMP JET X 71051722,2110891,CDM,278,RC,,,both,,,1688.11,1012.87,,1266.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1266.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,359.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1097.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,362.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1350.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1266.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1063.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.89,1350.49,
S&N PIN DRILL SET 114968,2110327,CDM,278,RC,,,both,,,379.59,227.75,,284.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,284.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,246.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,81.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.67,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,284.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.78,303.67,
S&N PLATE,2110762,CDM,278,RC,,,both,,,1986,1191.6,,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1290.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,426.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1588.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1251.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,1588.8,
S&N PLATE 6HOLE 7182-9006,2110763,CDM,278,RC,,,both,,,315.62,189.37,,236.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,236.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,67.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,236.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,198.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.67,252.5,
S&N POSTERIOR STABILIZED INSERT 71420820,2112314,CDM,278,RC,C1776,HCPCS,both,,,4274.15,2564.49,,3205.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3205.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,910.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,910.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2778.2,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,918.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3419.32,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3205.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3205.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3205.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3205.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,875.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2692.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,875.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,875.77,3419.32,
S&N PROV FIX PIN 71173322,2110542,CDM,278,RC,,,both,,,197.75,118.65,,148.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,148.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,42.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,148.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,124.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.52,158.2,
S&N SAW BLADE 71440397,2110636,CDM,278,RC,,,both,,,171.02,102.61,,128.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,128.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,36.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,107.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.04,136.82,
S&N SCREW 7182-5236,2110760,CDM,278,RC,,,both,,,205.92,123.55,,154.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,154.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,44.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,154.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.19,164.74,
S&N SCREW CANNULATED 121633,2110749,CDM,278,RC,,,both,,,551.67,331,,413.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,413.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,358.59,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,118.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,347.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.04,441.34,
S&N SEV TAP 7117-3318,2110761,CDM,278,RC,,,both,,,222.89,133.73,,167.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,167.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,47.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,167.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,140.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.67,178.31,
S&N SHORT HALF PIN TIN 71065308,2110889,CDM,278,RC,,,both,,,283.04,169.82,,212.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,212.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,60.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,212.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,178.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.99,226.43,
S&N SUPERIOR CLAV PLATE 8 HOLE 7182-3409,2110910,CDM,278,RC,,,both,,,1006.27,603.76,,754.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,754.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,214.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,216.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,805.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,754.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,633.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.18,805.02,
S&N TIBIAL PLATE 71820204,2110876,CDM,278,RC,C1776,HCPCS,both,,,1986,1191.6,,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1290.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,426.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1588.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1251.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,1588.8,
S&N TRIGEN TAN NAIL 71647238,2110837,CDM,278,RC,,,both,,,3574.91,2144.95,,2681.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2681.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,761.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,761.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2323.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,768.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2859.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2681.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2681.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2252.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.5,2859.93,
S&N TROCAR PIN 71210002,2110758,CDM,278,RC,,,both,,,230,138,,172.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,172.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,49.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,144.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.13,184,
S&N TWIST DRILL 71152128,2110828,CDM,278,RC,,,both,,,247.19,148.31,,185.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,185.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,160.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,53.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,185.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.65,197.75,
S&N WASHERS 121680,2110750,CDM,278,RC,,,both,,,111.29,66.77,,83.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,83.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,23.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,83.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.8,89.03,
SIMPLEX K WIRE,2109959,CDM,278,RC,,,both,,,128.67,77.2,,96.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,96.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,27.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,102.94,
SIMPLEX K WIRE .62X9 TK-062-9S,2112599,CDM,278,RC,,,both,,,128.67,77.2,,96.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,96.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,27.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,102.94,
SIMPLEX STEINMAN PIN,2109961,CDM,278,RC,C1713,HCPCS,both,,,173.47,104.08,,130.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,130.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,37.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,130.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.54,138.78,
SIMPLEX STEINMAN PIN 7/64X9,2112012,CDM,278,RC,C1713,HCPCS,both,,,133.78,80.27,,100.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,100.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,28.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,107.02,
SIMPLEX STEINMAN PIN3/16MM 4.8/9/64X9,2111787,CDM,278,RC,C1713,HCPCS,both,,,158.92,95.35,,119.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,119.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,34.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,119.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,100.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.56,127.14,
SMITH&NEPHEW NON LOCKING SCREW 7182-3026,2110538,CDM,278,RC,,,both,,,129.85,77.91,,97.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,97.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,27.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,97.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.61,103.88,
SMITH&NEPHEW PATELLA COMP 35MM 71420578,2110325,CDM,278,RC,C1713,HCPCS,both,,,1957.36,1174.42,,1468.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1468.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,416.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1272.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,420.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1565.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1468.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1468.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1468.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1468.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1233.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.06,1565.89,
SMITH&NEPHEW PATELLAR 32MM 71420576,2109967,CDM,278,RC,C1776,HCPCS,both,,,1957.36,1174.42,,1468.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1468.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,416.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1272.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,420.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1565.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1468.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1468.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1468.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1468.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1233.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.06,1565.89,
SMITH&NEPHEW PIN&DRILL SET 114968,2109893,CDM,278,RC,,,both,,,948.87,569.32,,711.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,711.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,616.77,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,204.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,759.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,711.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,597.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.42,759.1,
SMITH&NEPHEW PLATE 7182-2906,2110536,CDM,278,RC,,,both,,,2244.23,1346.54,,1683.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1683.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,478.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,478.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1458.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,482.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1795.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1683.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1683.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1683.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1683.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,459.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1413.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,459.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,459.84,1795.38,
SMITH&NEPHEW R TIBIAL BASEPLATE 71420184,2110324,CDM,278,RC,C1713,HCPCS,both,,,4777.55,2866.53,,3583.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3583.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1017.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1017.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3105.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1027.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3822.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3583.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3583.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3583.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3583.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,978.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3009.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,978.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,978.92,3822.04,
SMITH&NEPHEW SCREW 5.0X45 71642245,2109873,CDM,278,RC,,,both,,,360.18,216.11,,270.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,270.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,234.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,77.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,270.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,226.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.8,288.14,
SMITH&NEPHEW SCREW 5.0X65,2109872,CDM,278,RC,,,both,,,443.56,266.14,,332.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,332.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,288.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,95.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,332.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,279.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.89,354.85,
SMITH&NEPHEW SCREW 71755040,2110484,CDM,278,RC,C1713,HCPCS,both,,,430.3,258.18,,322.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,322.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,279.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,92.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,322.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,271.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.17,344.24,
SMITH&NEPHEW SHORT PROFIX SPIKE 71512449,2109896,CDM,278,RC,,,both,,,51.03,30.62,,38.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,38.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,10.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,38.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.46,40.82,
SMITH&NEPHEW SLEEVE HN1200,2109943,CDM,278,RC,,,both,,,377.36,226.42,,283.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,283.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,81.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,301.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,283.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,237.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.32,301.89,
SMITH&NEPHEW TIBIAL 5 L 71420168,2109965,CDM,278,RC,C1713,HCPCS,both,,,4299.72,2579.83,,3224.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.01,3439.78,
SMITH&NEPHEW TIBIAL BASEPLATE 71420186,2109890,CDM,278,RC,C1713,HCPCS,both,,,3583.08,2149.85,,2687.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2687.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,763.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,763.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2329,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,770.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2866.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2687.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2687.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2687.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2687.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,734.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2257.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,734.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,734.17,2866.46,
SMITH&NEPHEW TROCAR 71751136,2110479,CDM,278,RC,,,both,,,335.46,201.28,,251.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,251.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,218.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,72.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,268.37,
SOU ORT 1.3 COMP PLATE 6 HOLE 7005-13006,2113074,CDM,278,RC,C1776,HCPCS,both,,,2093.94,1256.36,,1570.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1570.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,446.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1361.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,450.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1675.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1570.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1319.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.05,1675.15,
SOU ORT 1.3 MET NECK PLATE 7005-1303R,2113075,CDM,278,RC,C1776,HCPCS,both,,,2093.94,1256.36,,1570.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1570.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,446.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1361.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,450.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1675.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1570.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1570.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1319.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.05,1675.15,
SOU ORT 11MM POLARUS NAIL,2113091,CDM,278,RC,C1713,HCPCS,both,,,4302.62,2581.57,,3226.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3226.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,916.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2796.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,925.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3442.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2710.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,3442.1,
SOU ORT 171 MM WRIST SPANNING PLATE,2112716,CDM,278,RC,C1776,HCPCS,both,,,3241.27,1944.76,,2430.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2430.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,690.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,690.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2106.83,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,696.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2593.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2430.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2430.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2430.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2430.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,664.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2042,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,664.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,664.14,2593.02,
SOU ORT 2.3 X12MM LAG SCREW,2113077,CDM,278,RC,C1713,HCPCS,both,,,275.37,165.22,,206.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,206.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,59.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,173.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.42,220.3,
SOU ORT 2.3MM X 14/16/18/20,2113098,CDM,278,RC,C1713,HCPCS,both,,,246.69,148.01,,185.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,185.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,160.35,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,53.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,185.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.55,197.35,
SOU ORT 2.3MM X 16MM SCREW,2113099,CDM,278,RC,C1713,HCPCS,both,,,246.69,148.01,,185.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,185.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,160.35,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,53.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,185.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.55,197.35,
SOU ORT 3.5 HEX SCREW,2113148,CDM,278,RC,C1713,HCPCS,both,,,319.07,191.44,,239.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,239.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,207.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,68.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,239.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,201.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.38,255.26,
SOU ORT 3.5MM X 14/16,2113096,CDM,278,RC,C1713,HCPCS,both,,,240.95,144.57,,180.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,180.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,192.76,
SOU ORT 3.5MM X 18MM SCREW,2113097,CDM,278,RC,C1713,HCPCS,both,,,240.95,144.57,,180.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,180.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,156.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.37,192.76,
SOU ORT 4.0 STEINMANN PIN,2112307,CDM,278,RC,,,both,,,141.42,84.85,,106.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,106.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,30.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,89.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.98,113.14,
SOU ORT 5 HOLE COMP PLATE 7008-0105,2113006,CDM,278,RC,C1776,HCPCS,both,,,1674.34,1004.6,,1255.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1255.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,356.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1088.32,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,359.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1339.47,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1255.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1255.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1255.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1255.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1054.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.07,1339.47,
SOU ORT 6 HOLE 1/3 TUBULAR PLATE,2112895,CDM,278,RC,C1776,HCPCS,both,,,326.45,195.87,,244.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,244.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.19,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,70.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,261.16,
SOU ORT 6 HOLE HUMERAL PLATE,2113186,CDM,278,RC,C1776,HCPCS,both,,,4362.96,2617.78,,3272.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3272.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,929.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,929.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2835.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,938.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3490.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2748.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,3490.37,
SOU ORT 6 HOLE LEFT NAR CLAV PLATE,2112689,CDM,278,RC,C1776,HCPCS,both,,,2703.75,1622.25,,2027.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2027.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,575.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,575.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1757.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,581.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2163,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2027.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2027.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2027.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2027.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,554,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1703.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,554,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,554,2163,
SOU ORT 7 HOLE PLATE,2113146,CDM,278,RC,C1713,HCPCS,both,,,4362.96,2617.78,,3272.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3272.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,929.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,929.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2835.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,938.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3490.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2748.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,3490.37,
SOU ORT 8 HOLE PLATE,2113164,CDM,278,RC,C1713,HCPCS,both,,,4362.96,2617.78,,3272.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3272.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,929.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,929.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2835.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,938.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3490.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3272.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2748.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.97,3490.37,
SOU ORT 8MM X 200 POLARUS,2113051,CDM,278,RC,C1713,HCPCS,both,,,3535.53,2121.32,,2651.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2651.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,753.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,753.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2298.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,760.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2828.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2651.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2651.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2651.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2651.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2227.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.43,2828.42,
SOU ORT 8MM X 200 POLARUS,2113093,CDM,278,RC,C1713,HCPCS,both,,,4302.62,2581.57,,3226.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3226.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,916.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2796.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,925.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3442.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2710.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,3442.1,
SOU ORT 8MM X 220 POLARUS,2113056,CDM,278,RC,C1776,HCPCS,both,,,4302.62,2581.57,,3226.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3226.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,916.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2796.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,925.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3442.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2710.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.61,3442.1,
SOU ORT 8MM X 280 POLARUS HR-0828S,2113066,CDM,278,RC,C1713,HCPCS,both,,,3687.96,2212.78,,2765.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2765.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,785.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,785.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2397.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,792.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2950.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2765.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2765.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2765.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2765.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,755.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2323.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,755.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,755.66,2950.37,
SOU ORT 9DEGREE LEFT LOCK PLATE 70-0036,2112103,CDM,278,RC,C1776,HCPCS,both,,,2622.54,1573.52,,1966.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1966.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,558.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,558.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1704.65,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,563.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2098.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1966.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1966.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1966.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1966.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1652.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.36,2098.03,
SOU ORT ACCTRAK 100MM SCREW AP-67100-S,2111814,CDM,278,RC,,,both,,,1279.66,767.8,,959.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,959.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,272.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,831.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,275.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1023.73,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,959.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,806.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.2,1023.73,
SOU ORT ACCTRAK 40MM 45MM SCREW,2112845,CDM,278,RC,,,both,,,1357.72,814.63,,1018.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1018.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,289.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,882.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,291.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1086.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1018.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1018.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1018.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1018.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,855.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.2,1086.18,
SOU ORT ACCTRAK PLUS SCREW,2111813,CDM,278,RC,,,both,,,1094.63,656.78,,820.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,820.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,233.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,711.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,235.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,875.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,820.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,820.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,820.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,820.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,689.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.29,875.7,
SOU ORT ACCTRAK2 SCREW AT2-S26-S,2111501,CDM,278,RC,,,both,,,955.13,573.08,,716.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,716.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,620.83,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,205.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,764.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,716.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,601.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.71,764.1,
SOU ORT ACU FUSION DEVICE ATF-270-S,2112308,CDM,278,RC,C1713,HCPCS,both,,,1068.86,641.32,,801.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,801.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,694.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,229.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,801.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,673.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.01,855.09,
SOU ORT ACULOC VDV PLATE,2112627,CDM,278,RC,C1713,HCPCS,both,,,2728,1636.8,,2046,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2046,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,581.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1773.2,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,586.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2182.4,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2046,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,558.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1718.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,558.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,558.97,2182.4,
SOU ORT ACUTRAK MICRO 24 MM AT2-C24,2112342,CDM,278,RC,,,both,,,1177.82,706.69,,883.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,883.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,250.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,765.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,253.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,883.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,883.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,883.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,883.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,742.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.34,942.26,
SOU ORT ACUTRAK SCREW,2113120,CDM,278,RC,C1713,HCPCS,both,,,1166.5,699.9,,874.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,874.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,758.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,250.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,933.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,874.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,734.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.02,933.2,
SOU ORT CORT SCREW,2111551,CDM,278,RC,C1713,HCPCS,both,,,296.13,177.68,,222.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,222.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,63.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,186.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,236.9,
SOU ORT CORT SCREW,2112858,CDM,278,RC,C1713,HCPCS,both,,,296.13,177.68,,222.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,222.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,63.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,186.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,236.9,
SOU ORT CRV MEDIAL/LATER PLATE7005-08007,2112685,CDM,278,RC,C1776,HCPCS,both,,,965.74,579.44,,724.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,724.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,627.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,207.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,772.59,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,724.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,724.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,608.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.88,772.59,
SOU ORT DORSAL PLATE,2113134,CDM,278,RC,C1713,HCPCS,both,,,2378.87,1427.32,,1784.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1784.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,506.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1546.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,511.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1903.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1784.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1498.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.43,1903.1,
SOU ORT DORSAL RADIUS PLATE,2113095,CDM,278,RC,C1776,HCPCS,both,,,2378.87,1427.32,,1784.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1784.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,506.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1546.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,511.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1903.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1784.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1784.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1498.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.43,1903.1,
SOU ORT EXTRA LNG DISTAL RAD PLATE,2112744,CDM,278,RC,C1776,HCPCS,both,,,2622.54,1573.52,,1966.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1966.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,558.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,558.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1704.65,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,563.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2098.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1966.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1966.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1966.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1966.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1652.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,537.36,2098.03,
SOU ORT GUIDE WIRE,2112415,CDM,278,RC,C1769,HCPCS,both,,,119.36,71.62,,89.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,89.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,25.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,75.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.46,95.49,
SOU ORT GUIDE WIRE .035 WS-0906-ST,2112343,CDM,278,RC,C1769,HCPCS,both,,,657.34,394.4,,493.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,493.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,141.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,525.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,414.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.69,525.87,
SOU ORT GUIDE WIRE .094 WS-2408ST,2112027,CDM,278,RC,,,both,,,234.04,140.42,,175.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,175.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,152.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,50.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,175.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,147.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,187.23,
SOU ORT GUIDE WIRE 2.0 MM,2113048,CDM,278,RC,C1769,HCPCS,both,,,281.14,168.68,,210.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,210.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,182.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,60.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.91,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,210.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,177.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.61,224.91,
SOU ORT GUIDE WIRE WS-1406-ST,2112516,CDM,278,RC,,,both,,,238.65,143.19,,178.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,178.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.92,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,178.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,150.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.9,190.92,
SOU ORT GUIDE WIRE WS-1505ST,2111503,CDM,278,RC,C1769,HCPCS,both,,,234.07,140.44,,175.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,175.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,152.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,50.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,175.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,147.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.96,187.26,
SOU ORT HEX LAG SCREW 3004-23010,2112686,CDM,278,RC,C1713,HCPCS,both,,,270.95,162.57,,203.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,203.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,58.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,203.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,170.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.52,216.76,
SOU ORT HEX SCREW,2113417,CDM,278,RC,C1713,HCPCS,both,,,325.63,195.38,,244.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,244.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,70.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.72,260.5,
SOU ORT K WIRE WS-1609STT,2111815,CDM,278,RC,,,both,,,248.32,148.99,,186.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,186.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,161.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,53.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,198.66,
SOU ORT LARGE MTP PLATE,2113211,CDM,278,RC,C1713,HCPCS,both,,,4177.3,2506.38,,3132.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3132.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,889.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,889.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2715.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,898.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3341.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3132.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3132.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3132.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3132.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2631.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.93,3341.84,
SOU ORT LOCKING SCREW,2112475,CDM,278,RC,C1713,HCPCS,both,,,310.06,186.04,,232.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,232.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,66.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,248.05,
SOU ORT LOCKING SCREW,2112672,CDM,278,RC,C1713,HCPCS,both,,,319.11,191.47,,239.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,239.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,207.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,68.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,239.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,201.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.39,255.29,
SOU ORT LOCKING SCREW,2112688,CDM,278,RC,C1713,HCPCS,both,,,218.55,131.13,,163.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,163.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,142.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,46.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,137.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.78,174.84,
SOU ORT LOCKING SCREW,2113172,CDM,278,RC,C1713,HCPCS,both,,,325.63,195.38,,244.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,244.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,70.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.72,260.5,
SOU ORT MICRO SCREW #11 AT2-C11-S,2111810,CDM,278,RC,,,both,,,1147.68,688.61,,860.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,860.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,244.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,745.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,246.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,918.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,860.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,860.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,723.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.16,918.14,
SOU ORT MINI SCREW AT2-066,2111693,CDM,278,RC,,,both,,,1280.67,768.4,,960.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,960.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,272.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,832.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,275.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1024.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,960.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,960.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,806.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.41,1024.54,
SOU ORT MINI SCREW AT2-M18-S,2113032,CDM,278,RC,,,both,,,1201.45,720.87,,901.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,901.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,255.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,780.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,258.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,961.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,901.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,901.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,901.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,901.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,756.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.18,961.16,
SOU ORT NON LOCKING SCREW,2112524,CDM,278,RC,C1713,HCPCS,both,,,348.58,209.15,,261.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,261.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,74.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,278.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,261.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,219.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.42,278.86,
SOU ORT NON LOCKING SCREW,2112690,CDM,278,RC,C1713,HCPCS,both,,,428.6,257.16,,321.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,321.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,278.59,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,92.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,321.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,270.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.82,342.88,
SOU ORT NONLOCKING SCREW,2112610,CDM,278,RC,C1713,HCPCS,both,,,312.54,187.52,,234.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,234.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,67.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,250.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,234.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.04,250.03,
SOU ORT NONLOCKING SCREW 3105-40014,2113008,CDM,278,RC,C1713,HCPCS,both,,,331.65,198.99,,248.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,248.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,71.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.32,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.96,265.32,
SOU ORT NONLOCKING SCREW CA-4042,2113007,CDM,278,RC,C1713,HCPCS,both,,,331.65,198.99,,248.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,248.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,71.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,265.32,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,208.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.96,265.32,
SOU ORT PLATE BLUE NARROW DORSAL,2112839,CDM,278,RC,C1776,HCPCS,both,,,2545.78,1527.47,,1909.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1909.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,542.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,542.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1654.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,547.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2036.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1909.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1909.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1909.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1909.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,521.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1603.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,521.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,521.63,2036.62,
SOU ORT PLATE TACKS PL-PTACK,2112474,CDM,278,RC,C1713,HCPCS,both,,,270.46,162.28,,202.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,202.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.8,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,58.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,216.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,170.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.42,216.37,
SOU ORT POLARUS WITNESS DRILL,2113055,CDM,278,RC,,,both,,,426.16,255.7,,319.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,319.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,277,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,91.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,268.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.32,340.93,
SOU ORT SCREW 3.5MM HCO3250-3325-3200-34,2113058,CDM,278,RC,C1713,HCPCS,both,,,441.46,264.88,,331.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,331.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,94.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,353.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,331.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.46,353.17,
SOU ORT SCREW 3.5MM X 25MM,2113053,CDM,278,RC,C1713,HCPCS,both,,,386.28,231.77,,289.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,289.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,251.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,243.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,309.02,
SOU ORT SCREW 3.5MM X 40MM,2113094,CDM,278,RC,C1713,HCPCS,both,,,386.28,231.77,,289.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,289.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,251.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,243.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,309.02,
SOU ORT SCREW 30-0023-S,2112871,CDM,278,RC,C1713,HCPCS,both,,,1189.43,713.66,,892.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,892.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,253.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,773.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,255.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,951.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,892.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.71,951.54,
SOU ORT SCREW 5.0MM,2113057,CDM,278,RC,C1713,HCPCS,both,,,441.46,264.88,,331.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,331.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,94.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,353.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,331.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.46,353.17,
SOU ORT SCREW 5.0MM X 30MM 45MM,2113052,CDM,278,RC,C1713,HCPCS,both,,,387.1,232.26,,290.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,290.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,251.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.68,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,290.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,243.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.32,309.68,
SOU ORT SCREW 5.3MM X 45MM,2113092,CDM,278,RC,C1713,HCPCS,both,,,386.28,231.77,,289.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,289.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,251.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,309.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,243.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.15,309.02,
SOU ORT STD ACITRAK SCREW AT2-S34-S,2111804,CDM,278,RC,,,both,,,1217.59,730.55,,913.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,913.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,791.43,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,261.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,974.07,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,913.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.48,974.07,
SOU ORT STR PLATE 10 HOLE 7005-13010,2112684,CDM,278,RC,C1776,HCPCS,both,,,524.51,314.71,,393.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,393.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,419.61,
SOU ORT TAP DRILL HR-0105,2113049,CDM,278,RC,C1734,HCPCS,both,,,268,160.8,,201,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,201,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.2,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,57.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.4,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.91,214.4,
STR E KNOTILUS ANCHOR SYSTEM,2113139,CDM,278,RC,C1713,HCPCS,both,,,928.82,557.29,,696.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,696.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,603.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,199.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,743.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,696.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,696.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,585.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,190.32,743.06,
STR E KNOTILUS IMPLANT LOOP 3910-500-107,2112766,CDM,278,RC,C1713,HCPCS,both,,,428.9,257.34,,321.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,321.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,278.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,92.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,321.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,270.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.88,343.12,
STR ENDO BIOSTEON SCREW,2112812,CDM,278,RC,,,both,,,1822.95,1093.77,,1367.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1367.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,388.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1184.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,391.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1458.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1367.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1367.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1367.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1367.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1148.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.52,1458.36,
STR ENDO FORCE FIBER #2,2112813,CDM,278,RC,,,both,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,80.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,23.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22,85.9,
STR ENDO KNOTILUS ANCHOR,2112767,CDM,278,RC,,,both,,,608.93,365.36,,456.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,456.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,395.8,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,130.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,487.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,456.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,456.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,383.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.77,487.14,
STR LINER CEMENTLESS,2113182,CDM,278,RC,C1776,HCPCS,both,,,4333.8,2600.28,,3250.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3250.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,923.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,923.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2816.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,931.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3467.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3250.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3250.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3250.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3250.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,888,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2730.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,888,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,888,3467.04,
STR ORT 2.5M DRILL BIT,2113112,CDM,278,RC,,,both,,,497.15,298.29,,372.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,372.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,323.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,106.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,397.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,372.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,313.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.87,397.72,
STR ORT 3.1M DRILL BIT,2113113,CDM,278,RC,,,both,,,472.91,283.75,,354.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,354.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,307.39,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,101.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.33,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,354.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,297.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.9,378.33,
STR ORT 6 HOLE MEDICAL PLATE,2113123,CDM,278,RC,C1776,HCPCS,both,,,4154.97,2492.98,,3116.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3116.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,885.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,885.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2700.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,893.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3323.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3116.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3116.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3116.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3116.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,851.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2617.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,851.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,851.35,3323.98,
STR ORT 8 HOLE PLATE 430208,2111698,CDM,278,RC,C1713,HCPCS,both,,,361.34,216.8,,271.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,271.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,234.87,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,77.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.07,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,271.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,227.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.04,289.07,
STR ORT ACETABULAR SHELL 542-11--56F,2112056,CDM,278,RC,C1776,HCPCS,both,,,2574.46,1544.68,,1930.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1930.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,548.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,548.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1673.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,553.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2059.57,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1930.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1930.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1930.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1930.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1621.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527.51,2059.57,
STR ORT ANA FEM HEAD 06-3600,2111606,CDM,278,RC,C1776,HCPCS,both,,,1528.73,917.24,,1146.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1146.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,325.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,993.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,328.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1222.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1146.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,963.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.24,1222.98,
STR ORT ANATOMIC FEM HEAD CAP,2112913,CDM,278,RC,C1776,HCPCS,both,,,6732.84,4039.7,,5049.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5049.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1434.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1434.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4376.35,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1447.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5386.27,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5049.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5049.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5049.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5049.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1379.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4241.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1379.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1379.56,5386.27,
STR ORT ANKLE ARTHR NAIL1819-1120S,2111649,CDM,278,RC,,,both,,,5196.47,3117.88,,3897.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3897.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1106.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1106.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3377.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1117.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4157.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3897.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3897.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3897.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3897.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1064.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3273.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1064.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1064.76,4157.18,
STR ORT ANTIBIOTIC SIMPLEX CEMENT,2112899,CDM,278,RC,,,both,,,675.31,405.19,,506.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,506.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,438.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,145.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,506.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,506.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,425.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.37,540.25,
STR ORT ASYMMETRIC PATELLA 5551-G-381,2111955,CDM,278,RC,C1776,HCPCS,both,,,2218.12,1330.87,,1663.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1663.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,472.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1441.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,476.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1774.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1397.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,1774.5,
STR ORT BEADED CABLE 1.6,2109917,CDM,278,RC,,,both,,,959.69,575.81,,719.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,719.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,204.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,623.8,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,206.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,767.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,719.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,719.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,719.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,719.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,604.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.64,767.75,
STR ORT BONE SCREW 2030-6350-1,2110718,CDM,278,RC,,,both,,,139.6,83.76,,104.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,104.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,30.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.68,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,111.68,
STR ORT BONE SCREW 2030-6520-1,2113158,CDM,278,RC,,,both,,,298.09,178.85,,223.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,223.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,193.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,64.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.47,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,223.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.08,238.47,
STR ORT BONE SCREW 2030-6525-1,2113168,CDM,278,RC,,,both,,,298.09,178.85,,223.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,223.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,193.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,64.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.47,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,223.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.08,238.47,
STR ORT BRAID SUTURE3910-900-017,2112751,CDM,278,RC,C1713,HCPCS,both,,,167.19,100.31,,125.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,125.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,133.75,
STR ORT C-TAPER HEAD S-1400-HH82,2112798,CDM,278,RC,C1776,HCPCS,both,,,1655.21,993.13,,1241.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1241.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,352.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1075.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,355.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1324.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1241.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1042.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.15,1324.17,
STR ORT CANC BONE SCREW 2030-6530-1,2111607,CDM,278,RC,C1776,HCPCS,both,,,657.28,394.37,,492.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,492.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,141.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,525.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,492.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,414.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.68,525.82,
STR ORT CANCELLOUS BONE SCREW,2112220,CDM,278,RC,,,both,,,296.13,177.68,,222.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,222.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,63.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,186.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.68,236.9,
STR ORT CANNULA 3910-075-800,2112745,CDM,278,RC,,,both,,,95.61,57.37,,71.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,71.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,20.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.59,76.49,
STR ORT CEM STEM 5560-S-212,2111827,CDM,278,RC,C1776,HCPCS,both,,,2749.17,1649.5,,2061.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2061.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,585.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,585.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1786.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,591.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2199.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2061.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2061.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2061.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2061.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1731.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.3,2199.34,
STR ORT CEMENT 6191-1-100,2111477,CDM,278,RC,,,both,,,221.29,132.77,,165.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,165.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,47.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.34,177.03,
STR ORT CENTER SCREW 5573-6524,2112709,CDM,278,RC,,,both,,,200.24,120.14,,150.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,150.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,43.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.19,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,150.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.03,160.19,
STR ORT CENTER SCREW 5573-6528,2112659,CDM,278,RC,,,both,,,381.91,229.15,,286.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,286.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,82.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.53,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,286.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.25,305.53,
STR ORT CHAMPION SLING SHOT CAT02855,2112755,CDM,278,RC,C1713,HCPCS,both,,,837.31,502.39,,627.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,627.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,544.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,180.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,627.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,527.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.56,669.85,
STR ORT CINCHLOK SS ANCHOR CAT02462,2112754,CDM,278,RC,C1713,HCPCS,both,,,1001.16,600.7,,750.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,750.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,650.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,215.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,750.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,630.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.14,800.93,
STR ORT CINCHLOK SS ANCHOR CAT02463,2112753,CDM,278,RC,C1713,HCPCS,both,,,1074.7,644.82,,806.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,806.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,698.56,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,231.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,859.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,806.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,806.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,677.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.21,859.76,
STR ORT CLUS ACET SHELL 542-11-50E,2111663,CDM,278,RC,C1776,HCPCS,both,,,1999.96,1199.98,,1499.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1499.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,425.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,425.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1299.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,429.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1599.97,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1499.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1499.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1259.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.79,1599.97,
STR ORT CLUS ACET SHELL 542-11-50E,2113167,CDM,278,RC,C1776,HCPCS,both,,,3853.23,2311.94,,2889.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2889.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,820.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,820.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2504.6,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,828.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3082.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2889.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2889.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2889.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2889.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2427.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.53,3082.58,
STR ORT CLUS ACET SHELL 542-11-52E,2111793,CDM,278,RC,C1776,HCPCS,both,,,2038.22,1222.93,,1528.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1528.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,434.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,434.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1324.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,438.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1630.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1528.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1528.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1528.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1528.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1284.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.63,1630.58,
STR ORT CLUS ACET SHELL 542-11-56F,2111608,CDM,278,RC,C1776,HCPCS,both,,,1975.93,1185.56,,1481.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1481.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1284.35,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,424.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1580.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1481.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1481.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1481.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1481.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1244.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.87,1580.74,
STR ORT CLUS ACET SHELL 542-11-56F,2112758,CDM,278,RC,C1776,HCPCS,both,,,3766.09,2259.65,,2824.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2824.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,802.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,802.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2447.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,809.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3012.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2824.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2824.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2824.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2824.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2372.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.67,3012.87,
STR ORT CLUS ACET SHELL REV 542-11-52E,2111694,CDM,278,RC,C1776,HCPCS,both,,,4051.68,2431.01,,3038.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3038.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,863.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,863.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2633.59,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,871.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3241.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3038.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3038.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3038.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3038.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,830.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2552.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,830.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,830.19,3241.34,
STR ORT COMP SCREW 5MM 1818-0001S,2111648,CDM,278,RC,,,both,,,442.28,265.37,,331.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,331.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,287.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,95.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,353.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,331.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,278.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.62,353.82,
STR ORT CONDYLE 1895-5045S,2112772,CDM,278,RC,,,both,,,461.69,277.01,,346.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,346.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,300.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,99.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,346.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,290.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.6,369.35,
STR ORT DRILL BIT,2112790,CDM,278,RC,,,both,,,239.76,143.86,,179.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,179.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,155.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,51.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,179.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.13,191.81,
STR ORT FEMORAL NAIL 1828-0928S,2112809,CDM,278,RC,,,both,,,2119.35,1271.61,,1589.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1589.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,451.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,451.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1377.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,455.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1695.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1589.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1589.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,434.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1335.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,434.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,434.25,1695.48,
STR ORT FEMORAL NAIL 1828-1326S,2112649,CDM,278,RC,,,both,,,3660.9,2196.54,,2745.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2745.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,779.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,779.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2379.59,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,787.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2928.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2745.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2745.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2745.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2745.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2306.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.12,2928.72,
STR ORT FEMORAL PLATE 437504,2112799,CDM,278,RC,,,both,,,3908.96,2345.38,,2931.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2931.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,832.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,832.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2540.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,840.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3127.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2931.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2931.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2931.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2931.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2462.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800.95,3127.17,
STR ORT FLEXSPAN FINGER IPLANT,2113207,CDM,278,RC,C1776,HCPCS,both,,,3536.77,2122.06,,2652.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2652.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,753.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,753.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2298.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,760.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2829.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2652.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2652.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2652.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2652.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2228.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,724.68,2829.42,
STR ORT FORCE FIBER W/NEEDLE,2113142,CDM,278,RC,,,both,,,143.58,86.15,,107.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,107.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,30.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,107.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.42,114.86,
STR ORT GLENOID BASEPLATE,2112874,CDM,278,RC,C1776,HCPCS,both,,,1862.28,1117.37,,1396.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1396.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,396.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1210.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,400.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1489.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1396.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1396.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1396.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1396.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1173.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.58,1489.82,
STR ORT GUIDE WIRE 702460,2110423,CDM,278,RC,,,both,,,220.73,132.44,,165.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,165.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.47,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,47.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,165.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.23,176.58,
STR ORT HEAD,2112859,CDM,278,RC,C1776,HCPCS,both,,,1655.21,993.13,,1241.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1241.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,352.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1075.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,355.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1324.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1241.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1042.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.15,1324.17,
STR ORT HEAD 06-2600,2113108,CDM,278,RC,C1776,HCPCS,both,,,1689.49,1013.69,,1267.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1267.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,359.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1098.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,363.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1351.59,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1267.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1267.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1064.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.18,1351.59,
STR ORT HEAD 06-2605,2111565,CDM,278,RC,C1776,HCPCS,both,,,1640.28,984.17,,1230.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1230.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,349.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1066.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,352.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1312.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1033.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.09,1312.22,
STR ORT HEAD LOW FRICTION 06-2200,2113170,CDM,278,RC,C1776,HCPCS,both,,,1627.83,976.7,,1220.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1220.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,346.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1058.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,349.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1302.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1220.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1220.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1220.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1220.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1025.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.54,1302.26,
STR ORT HEAD LOW FRICTION 06-2205,2113161,CDM,278,RC,C1776,HCPCS,both,,,1860.4,1116.24,,1395.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1395.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,396.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1209.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,399.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1488.32,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1395.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1395.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1172.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.2,1488.32,
STR ORT HEX DRIVE BON CANC SCR5260-5-040,2111953,CDM,278,RC,,,both,,,259.28,155.57,,194.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,194.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,168.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,55.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,194.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.13,207.42,
STR ORT HIP STEM,2112770,CDM,278,RC,C1776,HCPCS,both,,,3193.5,1916.1,,2395.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2395.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,680.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,680.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2075.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,686.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2554.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2395.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2395.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2395.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2395.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2011.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.35,2554.8,
STR ORT HIP STEM 6070-0730A,2113156,CDM,278,RC,C1776,HCPCS,both,,,3141.87,1885.12,,2356.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2356.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,669.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2042.22,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,675.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2513.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2356.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2356.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2356.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2356.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1979.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.77,2513.5,
STR ORT HIP STEM 6070-0830A,2112846,CDM,278,RC,C1776,HCPCS,both,,,13180.48,7908.29,,9885.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,9885.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2807.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2807.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8567.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2833.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10544.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,9885.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9885.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9885.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9885.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2700.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8303.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2700.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2700.68,10544.38,
STR ORT HIP STEM 6070-0935A,2113109,CDM,278,RC,C1776,HCPCS,both,,,3141.87,1885.12,,2356.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2356.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,669.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,669.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2042.22,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,675.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2513.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2356.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2356.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2356.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2356.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1979.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.77,2513.5,
STR ORT HIP STEM 6070-1035A/0935A,2111553,CDM,278,RC,C1776,HCPCS,both,,,2455.63,1473.38,,1841.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1841.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,523.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1596.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,527.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1964.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1841.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1841.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1547.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.16,1964.5,
STR ORT HUMERAL NAIL 1830-0929S,2111615,CDM,278,RC,,,both,,,3138.59,1883.15,,2353.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2353.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,668.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,668.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2040.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,674.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2510.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2353.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2353.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2353.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2353.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1977.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.1,2510.87,
STR ORT HUMERAL PLATE R 627235,2112856,CDM,278,RC,C1776,HCPCS,both,,,4526.36,2715.82,,3394.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3394.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,964.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,964.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2942.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,973.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3621.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3394.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3394.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3394.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3394.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,927.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2851.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,927.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,927.45,3621.09,
STR ORT HUMERAL STEM,2112731,CDM,278,RC,C1776,HCPCS,both,,,9523.94,5714.36,,7142.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7142.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2028.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2028.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6190.56,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2047.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7619.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7142.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7142.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7142.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7142.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1951.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6000.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1951.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1951.46,7619.15,
STR ORT HYDROSET BONE PUTTY 10CC,2112863,CDM,278,RC,,,both,,,6280.99,3768.59,,4710.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4710.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1337.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1337.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4082.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1350.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5024.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4710.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4710.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4710.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4710.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1286.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3957.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1286.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1286.97,5024.79,
STR ORT K WIRE,2112908,CDM,278,RC,C1713,HCPCS,both,,,187.41,112.45,,140.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,140.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,40.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,140.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,118.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.4,149.93,
STR ORT K WIRE 0152-0218S,2112773,CDM,278,RC,,,both,,,272.36,163.42,,204.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,204.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,177.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,58.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,204.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,171.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.81,217.89,
STR ORT K WIRE 1210-6450S,2111548,CDM,278,RC,C1713,HCPCS,both,,,437.09,262.25,,327.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,327.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,284.11,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,93.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,349.67,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,327.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,327.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,275.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.56,349.67,
STR ORT K WIRE 1210-6450S,2112611,CDM,278,RC,C1713,HCPCS,both,,,325.36,195.22,,244.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,244.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,69.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,244.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.67,260.29,
STR ORT K WIRE 1806-0050S,2112229,CDM,278,RC,C1713,HCPCS,both,,,550.02,330.01,,412.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,412.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,357.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,118.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,412.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,346.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.7,440.02,
STR ORT K WIRE 1806-0050S,2112571,CDM,278,RC,C1713,HCPCS,both,,,286.57,171.94,,214.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,214.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,61.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,180.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.72,229.26,
STR ORT K WIRE 390191,2112800,CDM,278,RC,,,both,,,42.34,25.4,,31.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,31.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,9.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,33.87,
STR ORT K WIRE 390192,2112855,CDM,278,RC,,,both,,,161.45,96.87,,121.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,121.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,34.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,121.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.08,129.16,
STR ORT K WIRE 705002,2113114,CDM,278,RC,,,both,,,192.32,115.39,,144.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,144.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,41.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,121.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.41,153.86,
STR ORT KNEE TIB AUG HALF BLO 5546-A-202,2112085,CDM,278,RC,C1776,HCPCS,both,,,2429.14,1457.48,,1821.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1821.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,517.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,517.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1578.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,522.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1943.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1821.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1821.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1821.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1821.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1530.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.73,1943.31,
STR ORT KNEE TIB AUG HALF BLO 5546-A-202,2112092,CDM,278,RC,C1776,HCPCS,both,,,2429.14,1457.48,,1821.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1821.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,517.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,517.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1578.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,522.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1943.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1821.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1821.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1821.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1821.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1530.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.73,1943.31,
STR ORT KNEE TIB AUG HALF BLO 5546-A-202,2112093,CDM,278,RC,C1776,HCPCS,both,,,1660.73,996.44,,1245.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1245.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,353.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,353.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1079.47,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,357.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1328.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1245.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1245.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1245.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1245.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1046.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.28,1328.58,
STR ORT KNEE TIB AUGMENT 5546-A-302,2111789,CDM,278,RC,C1776,HCPCS,both,,,1343.42,806.05,,1007.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1007.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,286.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,286.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,873.22,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,288.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1074.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1007.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1007.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1007.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1007.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,846.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,275.27,1074.74,
STR ORT KURCHNER STRA,2112888,CDM,278,RC,,,both,,,926.63,555.98,,694.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,694.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,197.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,602.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,199.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,694.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,583.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.87,741.3,
STR ORT LAG SCREW,2111839,CDM,278,RC,,,both,,,1583.19,949.91,,1187.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1187.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,337.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1029.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,340.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1266.55,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1187.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1187.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1187.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1187.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,997.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.4,1266.55,
STR ORT LAG SCREW,2113192,CDM,278,RC,,,both,,,1165.76,699.46,,874.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,874.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,757.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,250.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,932.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,874.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,734.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.86,932.61,
STR ORT LATERAL TIB PLATE 627302,2113115,CDM,278,RC,C1776,HCPCS,both,,,4190.13,2514.08,,3142.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3142.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,892.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,892.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2723.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,900.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3352.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3142.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3142.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3142.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3142.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,858.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2639.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,858.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,858.56,3352.1,
STR ORT LOCK SCREW 4M,2111618,CDM,278,RC,,,both,,,486.82,292.09,,365.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,365.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,316.43,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,104.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,389.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,365.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,365.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,306.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.75,389.46,
STR ORT LOCK SCREW 5X35MM,2113080,CDM,278,RC,,,both,,,468.12,280.87,,351.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,351.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,304.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,100.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,351.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,351.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,294.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.92,374.5,
STR ORT LOCKING SCREW,2112811,CDM,278,RC,,,both,,,492.15,295.29,,369.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,369.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,105.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,393.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,369.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,310.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.84,393.72,
STR ORT LOCKING SCREW 18965035SOO,2111598,CDM,278,RC,,,both,,,471.25,282.75,,353.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,353.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,101.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,296.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.56,377,
STR ORT LONG NAIL 3525-1380S,2112786,CDM,278,RC,,,both,,,4702,2821.2,,3526.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3526.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3056.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3761.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3526.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2962.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.44,3761.6,
STR ORT MAX NA HIP STEM 6051-1140S,2111691,CDM,278,RC,C1776,HCPCS,both,,,9945.19,5967.11,,7458.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7458.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2118.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2118.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6464.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2138.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7956.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7458.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7458.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7458.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7458.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2037.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6265.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2037.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2037.77,7956.15,
STR ORT MAX NE HIP STEM 6051-0830S,2113160,CDM,278,RC,C1776,HCPCS,both,,,9717.25,5830.35,,7287.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7287.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2069.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2069.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6316.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2089.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7773.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7287.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7287.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7287.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7287.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1991.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6121.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1991.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1991.06,7773.8,
STR ORT MAX NE HIP STEM 6052-1035S,2111612,CDM,278,RC,C1776,HCPCS,both,,,5046.76,3028.06,,3785.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3785.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1074.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1074.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3280.39,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1085.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4037.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3785.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3179.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.08,4037.41,
STR ORT NAIL,2111546,CDM,278,RC,,,both,,,3175.74,1905.44,,2381.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2381.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,676.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,676.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2064.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,682.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2540.59,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2381.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2381.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2381.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2381.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2000.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650.71,2540.59,
STR ORT NAIL,2112793,CDM,278,RC,,,both,,,3577.86,2146.72,,2683.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2683.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,762.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,762.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2325.61,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,769.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2862.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2683.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2683.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2683.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2683.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,733.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2254.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,733.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,733.1,2862.29,
STR ORT NAIL,2112810,CDM,278,RC,,,both,,,2964.41,1778.65,,2223.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2223.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,631.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,631.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1926.87,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,637.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2371.53,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2223.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2223.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2223.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2223.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,607.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1867.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,607.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,607.41,2371.53,
STR ORT NECK A HIP STEM,2112860,CDM,278,RC,C1776,HCPCS,both,,,9880.16,5928.1,,7410.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7410.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2104.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2104.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6422.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2124.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7904.13,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7410.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7410.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7410.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7410.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2024.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6224.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2024.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2024.44,7904.13,
STR ORT NECK HIP STEM 6052-0935S,2112102,CDM,278,RC,C1776,HCPCS,both,,,4718.4,2831.04,,3538.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3538.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1005.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1005.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3066.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1014.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3774.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3538.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,966.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2972.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,966.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,966.8,3774.72,
STR ORT NONO PASS 45 DEGREE LEFT,2113135,CDM,278,RC,C1713,HCPCS,both,,,603.73,362.24,,452.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,452.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,392.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,129.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,482.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,380.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.7,482.98,
STR ORT OMNI CROSSFIRE INSER 2041C-3250,2111760,CDM,278,RC,C1776,HCPCS,both,,,2836.21,1701.73,,2127.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2127.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,604.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,604.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1843.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,609.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2268.97,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2127.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2127.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2127.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2127.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1786.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,581.14,2268.97,
STR ORT PRO CINCH RT IMPLANT,2112776,CDM,278,RC,C1776,HCPCS,both,,,1264.56,758.74,,948.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,948.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,269.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,821.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,271.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1011.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,948.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,948.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,948.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,948.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,259.11,1011.65,
STR ORT PTOX HUMERAL NAIL 1832-3822S,2112851,CDM,278,RC,,,both,,,4178.86,2507.32,,3134.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3134.15,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,890.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,890.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2716.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,898.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3343.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3134.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3134.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3134.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3134.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2632.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.25,3343.09,
STR ORT PTOX HUMERAL NAIL 1832-3828S,2111680,CDM,278,RC,,,both,,,4057.02,2434.21,,3042.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3042.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,864.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,864.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2637.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,872.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3245.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3042.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3042.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3042.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3042.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2555.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.28,3245.62,
STR ORT RADIAL HEAD PROSTHESIS,2111845,CDM,278,RC,,,both,,,6170.19,3702.11,,4627.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4627.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1314.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1314.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4010.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1326.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4936.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4627.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4627.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4627.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4627.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1264.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3887.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1264.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1264.27,4936.15,
STR ORT RADIAL HUMERAL HEAD,2112732,CDM,278,RC,,,both,,,4175.31,2505.19,,3131.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3131.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,889.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,889.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2713.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,897.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3340.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3131.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3131.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3131.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3131.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2630.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.52,3340.25,
STR ORT RADIAL HUMERAL HEAD,2113090,CDM,278,RC,,,both,,,4227.9,2536.74,,3170.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3170.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,900.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2748.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,909,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3382.32,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3170.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3170.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3170.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3170.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2663.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.3,3382.32,
STR ORT REAMER SHAFT 0227-8240S,2111659,CDM,278,RC,,,both,,,746.33,447.8,,559.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,559.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,158.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,485.11,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,160.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,597.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,559.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,470.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.92,597.06,
STR ORT RESTOR MOD HIP SYS 6276-1-323,2111873,CDM,278,RC,C1776,HCPCS,both,,,10175.51,6105.31,,7631.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7631.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2167.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2167.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6614.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2187.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8140.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7631.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7631.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7631.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7631.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2084.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6410.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2084.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2084.96,8140.41,
STR ORT RESTOR MOD HIP SYS 6276-7-019,2111872,CDM,278,RC,C1776,HCPCS,both,,,7290.92,4374.55,,5468.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5468.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1552.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1552.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4739.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1567.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5832.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5468.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5468.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5468.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5468.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1493.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4593.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1493.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1493.91,5832.74,
STR ORT RESTORATION INSERT,2113183,CDM,278,RC,C1776,HCPCS,both,,,3414.09,2048.45,,2560.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2560.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,727.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,727.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2219.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,734.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2731.27,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2560.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2560.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2560.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2560.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,699.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2150.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,699.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,699.55,2731.27,
STR ORT SCREW,2112395,CDM,278,RC,,,both,,,461.13,276.68,,345.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,345.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,299.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,99.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,290.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.49,368.9,
STR ORT SCREW,2112857,CDM,278,RC,,,both,,,255.16,153.1,,191.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,191.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,54.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.13,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,191.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,160.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.28,204.13,
STR ORT SCREW 3.5,2111699,CDM,278,RC,,,both,,,95.06,57.04,,71.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,71.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,20.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.48,76.05,
STR ORT SCREW 3.5X34/42/50/75MM,2113116,CDM,278,RC,,,both,,,247.45,148.47,,185.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,185.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,160.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,53.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,197.96,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,185.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,155.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.7,197.96,
STR ORT SCREW 36 30 40,2112441,CDM,278,RC,,,both,,,493.92,296.35,,370.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,370.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,321.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,106.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,395.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,370.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,311.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.2,395.14,
STR ORT SCREW 4.0X20/22/24/26/30/36/40/4,2113122,CDM,278,RC,,,both,,,268.05,160.83,,201.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,201.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,57.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,214.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,201.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.92,214.44,
STR ORT SCREW 4.0X46/60/70/75,2113117,CDM,278,RC,,,both,,,471.77,283.06,,353.83,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,353.83,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.65,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,101.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,377.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,353.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,297.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.67,377.42,
STR ORT SCREW 4.5X46X50X55,2112806,CDM,278,RC,,,both,,,152.99,91.79,,114.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,114.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,32.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.39,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.35,122.39,
STR ORT SCREW 4.5X46X50X55X80X90,2112805,CDM,278,RC,,,both,,,167.19,100.31,,125.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,125.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,133.75,
STR ORT SCREW 5.0X80/5.0X46,2112804,CDM,278,RC,,,both,,,310.06,186.04,,232.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,232.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,66.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.53,248.05,
STR ORT SCREW 50 325450,2112683,CDM,278,RC,,,both,,,447.74,268.64,,335.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,335.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,291.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,96.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,358.19,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,335.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,282.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.74,358.19,
STR ORT SCREW 5MM 1896-5042S/4030S,2111534,CDM,278,RC,,,both,,,491.19,294.71,,368.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,368.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,105.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.95,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.64,392.95,
STR ORT SCREW 6.5X85,2112803,CDM,278,RC,,,both,,,660.96,396.58,,495.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,495.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,140.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,429.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,142.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,528.77,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,495.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,416.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.43,528.77,
STR ORT SCREW 6.5X90,2113214,CDM,278,RC,,,both,,,654.47,392.68,,490.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,490.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,425.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,140.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,523.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,490.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,412.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.1,523.58,
STR ORT SCREW 8.0MMX85 SCREW,2113215,CDM,278,RC,,,both,,,667.45,400.47,,500.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,500.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,142.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,433.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,143.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,533.96,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,500.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,420.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.76,533.96,
STR ORT SHOULDER DRILL BIT 5901-1126,2112656,CDM,278,RC,,,both,,,370.16,222.1,,277.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,277.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.6,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,79.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,296.13,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,277.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,233.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.85,296.13,
STR ORT SHOULDER GLENOID BASEPLATE,2112658,CDM,278,RC,C1776,HCPCS,both,,,3670.2,2202.12,,2752.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2752.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,781.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,781.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2385.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,789.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2936.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2752.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2752.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2752.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2752.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,752.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2312.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,752.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,752.02,2936.16,
STR ORT SHOULDER GLENOID BASEPLATE,2112708,CDM,278,RC,C1776,HCPCS,both,,,2463.29,1477.97,,1847.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1847.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,524.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1601.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,529.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1970.63,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1847.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1551.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.73,1970.63,
STR ORT SHOULDER GLENOID BASEPLATE,2112791,CDM,278,RC,C1776,HCPCS,both,,,2367.94,1420.76,,1775.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1775.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,504.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1539.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,509.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1894.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1775.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1775.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1775.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1775.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1491.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.19,1894.35,
STR ORT SHOULDER GLENOSPHERE,2112660,CDM,278,RC,C1776,HCPCS,both,,,3435.81,2061.49,,2576.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2576.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,731.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,731.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2233.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,738.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2748.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2576.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2576.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2576.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2576.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2164.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704,2748.65,
STR ORT SHOULDER GLENOSPHERE,2112711,CDM,278,RC,C1776,HCPCS,both,,,2238.73,1343.24,,1679.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1679.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,476.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,476.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1455.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,481.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1790.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1679.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1679.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1679.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1679.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1410.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.72,1790.98,
STR ORT SHOULDER GLENOSPHERE,2112792,CDM,278,RC,C1776,HCPCS,both,,,1746.18,1047.71,,1309.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1309.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,371.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,371.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1135.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,375.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1396.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1309.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1309.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1309.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1309.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,357.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1100.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,357.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,357.79,1396.94,
STR ORT SHOULDER HUMERAL CUP,2112713,CDM,278,RC,C1776,HCPCS,both,,,1695.37,1017.22,,1271.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1271.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,361.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,361.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1101.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,364.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1271.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1271.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1271.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1271.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1068.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.38,1356.3,
STR ORT SHOULDER HUMERAL CUP 5570-3604,2112663,CDM,278,RC,C1776,HCPCS,both,,,3435.81,2061.49,,2576.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2576.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,731.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,731.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2233.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,738.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2748.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2576.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2576.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2576.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2576.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2164.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704,2748.65,
STR ORT SHOULDER HUMERAL INSERT,2112655,CDM,278,RC,C1776,HCPCS,both,,,2442.41,1465.45,,1831.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1831.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,520.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1587.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,525.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1953.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1831.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1831.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1831.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1831.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,500.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1538.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,500.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,500.45,1953.93,
STR ORT SHOULDER HUMERAL INSERT,2112714,CDM,278,RC,C1776,HCPCS,both,,,1776.24,1065.74,,1332.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1332.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,378.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1154.56,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,381.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1420.99,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1332.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1332.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1332.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1332.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1119.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.95,1420.99,
STR ORT SHOULDER HUMERAL INSERT,2112730,CDM,278,RC,C1776,HCPCS,both,,,2051.86,1231.12,,1538.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1538.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,437.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,437.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1333.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,441.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1641.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1538.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1538.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1292.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.43,1641.49,
STR ORT SHOULDER HUMERAL INSERT,2112742,CDM,278,RC,C1776,HCPCS,both,,,2749.3,1649.58,,2061.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2061.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,585.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,585.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1787.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,591.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2199.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2061.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2061.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2061.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2061.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1732.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.33,2199.44,
STR ORT SHOULDER MOD HUMERAL STEM,2112661,CDM,278,RC,C1776,HCPCS,both,,,9342.28,5605.37,,7006.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7006.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1989.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1989.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6072.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2008.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7473.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7006.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7006.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7006.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7006.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1914.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5885.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1914.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1914.23,7473.82,
STR ORT SHOULDER MOD HUMERAL STEM,2112712,CDM,278,RC,C1776,HCPCS,both,,,6087.04,3652.22,,4565.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4565.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1296.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1296.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3956.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1308.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4869.63,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4565.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4565.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4565.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4565.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1247.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3834.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1247.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1247.23,4869.63,
STR ORT SHOULDER MOD HUMERAL STEM,2112789,CDM,278,RC,C1776,HCPCS,both,,,5851.55,3510.93,,4388.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4388.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1246.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1246.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3803.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1258.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4681.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4388.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4388.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4388.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4388.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1198.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3686.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1198.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1198.98,4681.24,
STR ORT SHOULDER MOD HUMERAL STEM,2113089,CDM,278,RC,C1776,HCPCS,both,,,9642.56,5785.54,,7231.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,7231.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2053.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2053.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6267.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2073.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7714.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,7231.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7231.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7231.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7231.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1975.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6074.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1975.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1975.76,7714.05,
STR ORT SHOULDER PILOT WIRE 5901-1119,2112657,CDM,278,RC,C1776,HCPCS,both,,,277.01,166.21,,207.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,207.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,59.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,174.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.76,221.61,
STR ORT SHOULDER PILOT WIRE 5901-1119,2112706,CDM,278,RC,C1776,HCPCS,both,,,112.01,67.21,,84.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,84.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,24.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.95,89.61,
STR ORT SLING SHOT CAT02862,2112749,CDM,278,RC,C1713,HCPCS,both,,,417.97,250.78,,313.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,313.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,89.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,334.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,263.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,334.38,
STR ORT STERILE PIN PACK,2112077,CDM,278,RC,,,both,,,955.23,573.14,,716.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,716.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,620.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,205.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,764.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,716.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,716.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,601.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.73,764.18,
STR ORT SUPRACONDYLAR NAIL,2112178,CDM,278,RC,,,both,,,4393.04,2635.82,,3294.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3294.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,935.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2855.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,944.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3514.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3294.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3294.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3294.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3294.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2767.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900.13,3514.43,
STR ORT T2 SYSTEM END CAP 1822-0005S,2113079,CDM,278,RC,,,both,,,458.77,275.26,,344.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,344.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,298.2,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,98.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,344.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,289.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94,367.02,
STR ORT TIB AUGMENT HALF BLO 5546-A-402,2111828,CDM,278,RC,C1776,HCPCS,both,,,2403.58,1442.15,,1802.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1802.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,511.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1562.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,516.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1922.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1802.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1802.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1802.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1802.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1514.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.49,1922.86,
STR ORT TIB INSERT 5532-G-416,2112168,CDM,278,RC,C1776,HCPCS,both,,,3637.96,2182.78,,2728.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2728.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,774.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,774.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2364.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,782.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2910.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2728.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2728.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2728.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2728.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,745.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2291.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,745.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,745.42,2910.37,
STR ORT TIB INSERT CAP 5532-G-419,2111545,CDM,278,RC,C1776,HCPCS,both,,,2437.05,1462.23,,1827.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1827.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,519.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1584.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,523.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1949.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1827.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1827.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1535.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.35,1949.64,
STR ORT TIB NAIL 1822-0934S,2113078,CDM,278,RC,,,both,,,3278.04,1966.82,,2458.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2458.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,698.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2130.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,704.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2622.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2458.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2458.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2458.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2458.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2065.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671.67,2622.43,
STR ORT TIBIAL INSERT,2112316,CDM,278,RC,C1776,HCPCS,both,,,4470.78,2682.47,,3353.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3353.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,952.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,952.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2906.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,961.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3576.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3353.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3353.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3353.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3353.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2816.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.06,3576.62,
STR ORT TRI ASYM PATELLA 5551-G-299,2112718,CDM,278,RC,C1776,HCPCS,both,,,1213.21,727.93,,909.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,909.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,788.59,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,260.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,970.57,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,764.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.59,970.57,
STR ORT TRI HEMIS SHELL,2112852,CDM,278,RC,C1776,HCPCS,both,,,4476.63,2685.98,,3357.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3357.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,953.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,953.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2909.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,962.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3581.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3357.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3357.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3357.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3357.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,917.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2820.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,917.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,917.26,3581.3,
STR ORT TRI STABLE FEMORA 5515-F-301,2112406,CDM,278,RC,C1776,HCPCS,both,,,3201.96,1921.18,,2401.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2401.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,682.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,682.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2081.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,688.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2561.57,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2401.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2401.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2401.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2401.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2017.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,656.08,2561.57,
STR ORT TRI TIB BEARING INS 5532-G-409,2113101,CDM,278,RC,C1776,HCPCS,both,,,1959.87,1175.92,,1469.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1469.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,417.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1273.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,421.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1567.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1469.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1469.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1234.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,401.58,1567.9,
STR ORT TRI TIB INS 5532-G-416/413,2112368,CDM,278,RC,C1776,HCPCS,both,,,4251.56,2550.94,,3188.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3188.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,905.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,905.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2763.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,914.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3401.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3188.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2678.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.14,3401.25,
STR ORT TRI TIB INS REVISIO 5532-G-325,2111830,CDM,278,RC,C1776,HCPCS,both,,,4599.29,2759.57,,3449.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3449.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,979.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,979.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2989.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,988.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3679.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3449.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3449.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3449.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3449.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2897.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.39,3679.43,
STR ORT TRI TIB INS REVISION 5532-G-509,2111634,CDM,278,RC,C1776,HCPCS,both,,,4251.56,2550.94,,3188.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3188.67,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,905.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,905.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2763.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,914.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3401.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3188.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2678.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,871.14,3401.25,
STR ORT TRI TIB INSERT,2111660,CDM,278,RC,C1776,HCPCS,both,,,24073.64,14444.18,,18055.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,18055.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5127.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5127.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15647.87,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,5175.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19258.91,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,18055.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18055.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18055.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18055.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4932.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15166.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4932.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4932.69,19258.91,
STR ORT TRI TIB INSERT 5537-G-228,2112087,CDM,278,RC,C1776,HCPCS,both,,,5507.89,3304.73,,4130.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4130.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1173.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1173.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3580.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1184.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4406.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1128.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3469.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1128.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1128.57,4406.31,
STR ORT TRI TIB INSERT 5537-G-228,2112096,CDM,278,RC,C1776,HCPCS,both,,,4511.33,2706.8,,3383.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3383.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,960.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2932.36,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,969.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3609.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2842.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.37,3609.06,
STR ORT TRI TIB INSERT 5537-G-325,2112188,CDM,278,RC,C1776,HCPCS,both,,,4763.76,2858.26,,3572.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3572.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1014.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1014.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3096.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1024.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3811.01,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3572.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3572.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3572.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3572.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,976.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3001.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,976.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,976.09,3811.01,
STR ORT TRI TIB INSERT 5537-G-409,2111821,CDM,278,RC,C1776,HCPCS,both,,,5696.71,3418.03,,4272.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4272.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1213.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1213.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3702.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1224.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4557.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4272.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4272.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4272.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4272.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1167.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3588.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1167.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1167.26,4557.37,
STR ORT TRI TRIT HEMIS SHELL 509-02-58F,2111952,CDM,278,RC,C1776,HCPCS,both,,,7017.85,4210.71,,5263.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5263.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1494.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1494.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4561.6,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1508.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5614.28,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5263.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5263.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5263.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5263.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1437.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4421.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1437.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1437.96,5614.28,
STR ORT TRID CONST ACET INSER,2112089,CDM,278,RC,C1776,HCPCS,both,,,6924.34,4154.6,,5193.26,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5193.26,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1474.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1474.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4500.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1488.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5539.47,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5193.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5193.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5193.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5193.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1418.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4362.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1418.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1418.8,5539.47,
STR ORT TRID CONST ACET INSER,2112912,CDM,278,RC,C1776,HCPCS,both,,,1872.93,1123.76,,1404.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1404.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,398.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,398.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1217.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,402.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1498.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1404.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1404.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1404.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1404.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1179.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,383.76,1498.34,
STR ORT TRID CONST ACET INSER 690-00-22E,2111715,CDM,278,RC,C1776,HCPCS,both,,,7679.41,4607.65,,5759.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5759.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1635.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1635.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4991.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1651.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6143.53,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5759.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5759.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5759.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5759.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1573.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4838.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1573.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1573.51,6143.53,
STR ORT TRID CONST ACET INSER 690-00-22E,2111971,CDM,278,RC,C1776,HCPCS,both,,,1140.47,684.28,,855.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,855.35,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,242.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,741.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,245.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,912.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,855.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,718.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.68,912.38,
STR ORT TRID CONST ACET INSER 690-00-22E,2113169,CDM,278,RC,C1776,HCPCS,both,,,6923.95,4154.37,,5192.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5192.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1474.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1474.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4500.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1488.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5539.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5192.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5192.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5192.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5192.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1418.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4362.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1418.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1418.72,5539.16,
STR ORT TRID CONST ACET INSER 690-00-28F,2111918,CDM,278,RC,C1776,HCPCS,both,,,7228.87,4337.32,,5421.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5421.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1539.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1539.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4698.77,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1554.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5783.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5421.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5421.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5421.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5421.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1481.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4554.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1481.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1481.2,5783.1,
STR ORT TRID CONST ACET INSER 690-00-28F,2112491,CDM,278,RC,C1776,HCPCS,both,,,2793.03,1675.82,,2094.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2094.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,594.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,594.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1815.47,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,600.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2234.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2094.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2094.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2094.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2094.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,572.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1759.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,572.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,572.29,2234.42,
STR ORT TRID CONST ACET INSER 690-10-22E,2113159,CDM,278,RC,C1776,HCPCS,both,,,6908.05,4144.83,,5181.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5181.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1471.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1471.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4490.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1485.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5526.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5181.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5181.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5181.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5181.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1415.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4352.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1415.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1415.46,5526.44,
STR ORT TRID CONST ACET INSER 690-10-28G,2111871,CDM,278,RC,C1776,HCPCS,both,,,7101.1,4260.66,,5325.83,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5325.83,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1512.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1512.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4615.72,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1526.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5680.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5325.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5325.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5325.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5325.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1455.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4473.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1455.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1455.02,5680.88,
STR ORT TRID POLY INSERT REV 623-00-36E,2111695,CDM,278,RC,C1776,HCPCS,both,,,3303.32,1981.99,,2477.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2477.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,703.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,703.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2147.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,710.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2642.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2477.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2477.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2477.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2477.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,676.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2081.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,676.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,676.85,2642.66,
STR ORT UNIV HEAD BIPOLAR UH1-50-26,2112771,CDM,278,RC,C1776,HCPCS,both,,,2236.27,1341.76,,1677.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1677.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,476.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,476.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1453.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,480.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1789.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1408.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,1789.02,
STR SCREW VALERIS MEDICAL,2112777,CDM,278,RC,C1713,HCPCS,both,,,597.18,358.31,,447.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,447.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,388.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,128.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,447.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,376.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.36,477.74,
STR SCREW VALERIS MEDICAL,2112783,CDM,278,RC,C1713,HCPCS,both,,,597.18,358.31,,447.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,447.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,388.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,128.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,447.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,376.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,122.36,477.74,
STRYKER 10 DEGREE INSERT 36MM,2110716,CDM,278,RC,C1776,HCPCS,both,,,4634.11,2780.47,,3475.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3475.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,987.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,987.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3012.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,996.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3707.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3475.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3475.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3475.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3475.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,949.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2919.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,949.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,949.53,3707.29,
STRYKER 10 GROOVE PLATE,2109922,CDM,278,RC,C1713,HCPCS,both,,,1819.76,1091.86,,1364.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1364.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,387.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1182.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,391.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1455.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1364.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1364.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1364.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1364.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1146.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.87,1455.81,
STRYKER 6 GROOVE PLATE,2109920,CDM,278,RC,C1713,HCPCS,both,,,1378.43,827.06,,1033.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1033.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,293.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,895.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,296.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1102.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1033.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1033.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1033.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1033.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,868.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.44,1102.74,
STRYKER 6.5 CANNULATED SCREW,2110468,CDM,278,RC,C1713,HCPCS,both,,,523.02,313.81,,392.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,392.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,339.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,392.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,329.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.17,418.42,
STRYKER 6.5 CANNULATED SCREW,2111508,CDM,278,RC,C1713,HCPCS,both,,,523.02,313.81,,392.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,392.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,339.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,392.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,329.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.17,418.42,
STRYKER 8 GROOVE PLATE,2109921,CDM,278,RC,C1713,HCPCS,both,,,1378.43,827.06,,1033.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1033.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,293.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,895.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,296.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1102.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1033.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1033.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1033.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1033.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,868.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.44,1102.74,
STRYKER ACETABULAR SHELL 542-11-62H,2110715,CDM,278,RC,C1776,HCPCS,both,,,1532.59,919.55,,1149.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1149.44,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,326.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,996.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,329.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1226.07,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1149.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1149.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,965.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.03,1226.07,
STRYKER ANATOMIC FEM HEAD CAP 06-3605,2111678,CDM,278,RC,C1776,HCPCS,both,,,1627.74,976.64,,1220.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1220.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,346.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1058.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,349.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1302.19,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1220.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1220.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1220.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1220.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1025.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,333.52,1302.19,
STRYKER ANATOMIC FEMORAL HEAD 06-3605,2110717,CDM,278,RC,C1776,HCPCS,both,,,4192.78,2515.67,,3144.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3144.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,893.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,893.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2725.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,901.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3354.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3144.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3144.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3144.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3144.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,859.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2641.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,859.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,859.1,3354.22,
STRYKER ANCHOR 3910-200-030,2112815,CDM,278,RC,,,both,,,862.55,517.53,,646.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,646.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,183.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,183.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,560.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,185.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,690.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,646.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,646.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,543.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.74,690.04,
STRYKER BEADED CABLE 1.6,2109919,CDM,278,RC,,,both,,,878.32,526.99,,658.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,658.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,570.91,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,188.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,702.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,658.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,658.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,658.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,658.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,553.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,179.97,702.66,
STRYKER BEADED CABLE 2.0,2109918,CDM,278,RC,,,both,,,922.34,553.4,,691.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,691.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,599.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,198.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,737.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,691.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,581.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.99,737.87,
STRYKER BONE SCREW REV,2111968,CDM,278,RC,,,both,,,299.94,179.96,,224.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,224.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,64.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.95,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,224.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,188.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.46,239.95,
STRYKER BONE SCREW REV 2030-6530-1,2111696,CDM,278,RC,,,both,,,601.43,360.86,,451.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,451.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,390.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,129.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,481.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,451.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,378.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.23,481.14,
STRYKER CANCELLOUS BONE SCREW,2112101,CDM,278,RC,,,both,,,132.4,79.44,,99.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,99.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,28.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.92,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,99.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,83.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.13,105.92,
STRYKER CANN SCREW 4.0X18MM 325018,2109863,CDM,278,RC,C1713,HCPCS,both,,,422.02,253.21,,316.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,316.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,274.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,90.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,316.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.47,337.62,
STRYKER CANN SCREW 5MM,2110424,CDM,278,RC,C1713,HCPCS,both,,,397.2,238.32,,297.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,297.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,85.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,317.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,297.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,297.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,250.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,317.76,
STRYKER CANNULATED SCREW 325030S,2109861,CDM,278,RC,C1713,HCPCS,both,,,367.81,220.69,,275.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,275.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,79.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,294.25,
STRYKER CANNULATED SCREW 4.0 24MM,2109862,CDM,278,RC,C1713,HCPCS,both,,,367.81,220.69,,275.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,275.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,79.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,294.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.36,294.25,
STRYKER LIGHTED STENT KIT 220-180-511,2112029,CDM,278,RC,C2617,HCPCS,both,,,542.02,325.21,,406.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,406.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,352.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,116.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,433.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,406.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.06,433.62,
STRYKER ORT 6 HOLE T PLATE 430206,2111604,CDM,278,RC,C1713,HCPCS,both,,,454.17,272.5,,340.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,340.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,295.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,97.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,340.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.06,363.34,
STRYKER ORT 7 HOLE REAM PLATE 430107,2111516,CDM,278,RC,C1776,HCPCS,both,,,579.99,347.99,,434.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,434.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,376.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,124.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,463.99,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,434.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,365.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.84,463.99,
STRYKER ORT 7 HOLE T PLATE 430207,2111610,CDM,278,RC,C1776,HCPCS,both,,,454.17,272.5,,340.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,340.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,295.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,97.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,363.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,340.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.06,363.34,
STRYKER ORT ANA FEM HEAD,2112236,CDM,278,RC,C1776,HCPCS,both,,,2880.77,1728.46,,2160.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2160.58,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,613.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,613.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1872.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,619.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2304.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2160.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2160.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,590.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1814.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,590.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,590.27,2304.62,
STRYKER ORT ANA FEM HEAD 06-3600,2112048,CDM,278,RC,C1776,HCPCS,both,,,3385.12,2031.07,,2538.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2538.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,721.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,721.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2200.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,727.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2708.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2538.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2538.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2538.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2538.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2132.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.61,2708.1,
STRYKER ORT ANK ARTH NAIL 02718191015SOW,2111960,CDM,278,RC,,,both,,,4616.82,2770.09,,3462.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3462.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,983.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,983.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3000.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,992.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3693.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3462.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3462.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3462.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3462.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,945.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2908.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,945.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,945.99,3693.46,
STRYKER ORT AXLE 6495-2-115,2111728,CDM,278,RC,C1776,HCPCS,both,,,1636.75,982.05,,1227.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1227.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1063.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,351.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1309.4,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1227.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1227.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1227.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1227.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1031.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.37,1309.4,
STRYKER ORT BONE PASTE 5CC PAST T43105,2111669,CDM,278,RC,,,both,,,1752.18,1051.31,,1314.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1314.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,373.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1138.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,376.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1401.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1314.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1314.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1314.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1314.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1103.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.02,1401.74,
STRYKER ORT BONE PUTTY 1CC PAST,2111670,CDM,278,RC,,,both,,,500.64,300.38,,375.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,375.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,325.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,107.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.51,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,375.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,315.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.58,400.51,
STRYKER ORT BUSH SM DIS FEMU 6495-2-105,2111730,CDM,278,RC,C1776,HCPCS,both,,,1129.54,677.72,,847.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,847.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,734.2,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,242.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,903.63,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,847.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,711.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.44,903.63,
STRYKER ORT C TAPER HEAD 02-2600,2111554,CDM,278,RC,C1776,HCPCS,both,,,1163.81,698.29,,872.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,872.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,247.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,247.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,756.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,250.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,931.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,872.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,872.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,872.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,872.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,733.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.46,931.05,
STRYKER ORT CANC SCREW 4.0 454026/28,2111605,CDM,278,RC,,,both,,,118.72,71.23,,89.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,89.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,25.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,94.98,
STRYKER ORT CEM STEM 5560-S-212,2112698,CDM,278,RC,C1776,HCPCS,both,,,2381.94,1429.16,,1786.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1786.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,507.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,507.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1548.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,512.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1905.55,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1786.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1786.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1786.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1786.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1500.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.06,1905.55,
STRYKER ORT CEM STEM 5566-S-013,2112094,CDM,278,RC,C1776,HCPCS,both,,,1651.08,990.65,,1238.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1238.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,351.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1073.2,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,354.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1320.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1238.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1238.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1238.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1238.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1040.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.31,1320.86,
STRYKER ORT CEMENTED STEM 5560-S-112,2111661,CDM,278,RC,C1776,HCPCS,both,,,2369.31,1421.59,,1776.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1776.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,504.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1540.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,509.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1895.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1776.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1776.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1776.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1776.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1492.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,485.47,1895.45,
STRYKER ORT CLUS ACET SHELL 542-11-50E,2111967,CDM,278,RC,C1776,HCPCS,both,,,2253.77,1352.26,,1690.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1690.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,480.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1464.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,484.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1803.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1690.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1419.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.8,1803.02,
STRYKER ORT CLUS ACET SHELL 542-11-50E,2112002,CDM,278,RC,C1776,HCPCS,both,,,4070.15,2442.09,,3052.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3052.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,866.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2645.6,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,875.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3256.12,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3052.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3052.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3052.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3052.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2564.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,833.97,3256.12,
STRYKER ORT CLUS ACET SHELL 542-11-50E,2112678,CDM,278,RC,C1776,HCPCS,both,,,3549.67,2129.8,,2662.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2662.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,756.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,756.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2307.29,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,763.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2839.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2662.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2662.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2662.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2662.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,727.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2236.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,727.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,727.33,2839.74,
STRYKER ORT CORTIAL SCREW 3.5 338610,2111515,CDM,278,RC,,,both,,,118.72,71.23,,89.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,89.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,25.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,94.98,
STRYKER ORT DALL-MILES PLATE 6704-3-080,2111754,CDM,278,RC,C1713,HCPCS,both,,,2876.52,1725.91,,2157.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2157.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,612.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,612.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1869.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,618.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2301.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2157.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2157.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1812.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.4,2301.22,
STRYKER ORT DIST FEMO COMP 6495-2-020,2111721,CDM,278,RC,C1776,HCPCS,both,,,11733.87,7040.32,,8800.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,8800.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2499.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2499.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7627.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2522.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9387.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,8800.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8800.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8800.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8800.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2404.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7392.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2404.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2404.27,9387.1,
STRYKER ORT FEM POST AUG,2111626,CDM,278,RC,C1776,HCPCS,both,,,2716.76,1630.06,,2037.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2037.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,578.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,578.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1765.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,584.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2173.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2037.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2037.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2037.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2037.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1711.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.66,2173.41,
STRYKER ORT FEM POST AUG 5540-A-201,2112187,CDM,278,RC,C1776,HCPCS,both,,,2096.12,1257.67,,1572.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1572.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,446.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1362.48,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,450.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1676.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1572.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1572.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1572.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1572.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1320.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.49,1676.9,
STRYKER ORT FEM POST AUG 5542-A-201,2111627,CDM,278,RC,C1776,HCPCS,both,,,2310.32,1386.19,,1732.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1732.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,492.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,492.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1501.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,496.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1848.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1732.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1732.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,473.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1455.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,473.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,473.38,1848.26,
STRYKER ORT FEMORAL HEAD 6260-9-128,2111535,CDM,278,RC,C1776,HCPCS,both,,,5248.91,3149.35,,3936.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3936.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1118.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1118.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3411.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1128.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4199.13,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3936.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3936.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3936.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3936.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3306.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.5,4199.13,
STRYKER ORT FEMORAL HEAD 6260-9-328,2111874,CDM,278,RC,C1776,HCPCS,both,,,1662.33,997.4,,1246.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1246.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,354.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1080.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,357.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1329.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1246.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1047.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.61,1329.86,
STRYKER ORT FEMORAL NAIL 1825-1434S,2112007,CDM,278,RC,,,both,,,3172.19,1903.31,,2379.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2379.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,675.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2061.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,682.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2537.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2379.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2379.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2379.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2379.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,649.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1998.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,649.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,649.98,2537.75,
STRYKER ORT FLAT TIBIAL WEDGE 6630-6-110,2111725,CDM,278,RC,C1713,HCPCS,both,,,1460.64,876.38,,1095.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1095.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,311.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,311.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,949.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,314.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1168.51,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1095.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1095.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1095.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1095.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,920.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.29,1168.51,
STRYKER ORT FLUTED STEM,2112500,CDM,278,RC,C1776,HCPCS,both,,,2599.84,1559.9,,1949.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1949.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,553.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,553.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1689.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,558.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2079.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1949.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1949.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1949.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1949.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,532.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1637.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,532.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,532.71,2079.87,
STRYKER ORT FLUTED STEM 5565-S-012,2112645,CDM,278,RC,C1776,HCPCS,both,,,2494.5,1496.7,,1870.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1870.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,531.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,531.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1621.43,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,536.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1995.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1870.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1870.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1870.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1870.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1571.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.12,1995.6,
STRYKER ORT FLUTED STEM 5566-S-013,2111628,CDM,278,RC,C1776,HCPCS,both,,,1962.24,1177.34,,1471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1471.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,417.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1275.46,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,421.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1569.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1471.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1236.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.06,1569.79,
STRYKER ORT HE/NE HIP STEM 6050-0745,2111573,CDM,278,RC,C1776,HCPCS,both,,,4847.57,2908.54,,3635.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3635.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1032.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1032.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3150.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1042.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3878.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3635.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3635.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3635.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3635.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,993.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3053.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,993.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,993.27,3878.06,
STRYKER ORT HEAD 06-2605,2112074,CDM,278,RC,C1776,HCPCS,both,,,645.67,387.4,,484.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,484.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,419.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,138.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,516.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,484.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,406.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.3,516.54,
STRYKER ORT HEAD LOW FRICTION 06-2200,2112245,CDM,278,RC,C1776,HCPCS,both,,,831.22,498.73,,623.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,623.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,177.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.29,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,178.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,664.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,623.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,623.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,623.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,623.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,523.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,170.32,664.98,
STRYKER ORT HEAD LOW FRICTION 06-2600,2111571,CDM,278,RC,C1776,HCPCS,both,,,1169.85,701.91,,877.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,877.39,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,249.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,249.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,760.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,251.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,935.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,877.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,877.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,877.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,877.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,737.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.7,935.88,
STRYKER ORT HEAD LOW FRICTION 06-2600,2111885,CDM,278,RC,C1776,HCPCS,both,,,665.08,399.05,,498.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,498.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,432.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,142.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,532.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,498.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,419,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.27,532.06,
STRYKER ORT HEAD LOW FRICTION 06-2805,2111972,CDM,278,RC,C1776,HCPCS,both,,,990.98,594.59,,743.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,743.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,211.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,644.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,213.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,792.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,743.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,743.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,624.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.05,792.78,
STRYKER ORT HEMISPHERIC SHEL 509-02-66H,2112004,CDM,278,RC,C1776,HCPCS,both,,,7049.36,4229.62,,5287.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5287.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1501.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1501.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4582.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1515.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5639.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5287.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5287.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5287.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5287.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1444.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4441.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1444.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1444.41,5639.49,
STRYKER ORT HIP STEM 6070-0730A,2111563,CDM,278,RC,C1776,HCPCS,both,,,3166.6,1899.96,,2374.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2374.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,674.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,674.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2058.29,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,680.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2533.28,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2374.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2374.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2374.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2374.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,648.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1994.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,648.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,648.84,2533.28,
STRYKER ORT HO TIB BEAR INS 5531-G-516,2111652,CDM,278,RC,C1776,HCPCS,both,,,5092.64,3055.58,,3819.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3819.48,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1084.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1084.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3310.22,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1094.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4074.11,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3819.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3819.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3819.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3819.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3208.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.48,4074.11,
STRYKER ORT HOW ROT HINGE TIB 6481-3-213,2111731,CDM,278,RC,C1776,HCPCS,both,,,1822.41,1093.45,,1366.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1366.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,388.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,388.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1184.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,391.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1457.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1366.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1366.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1366.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1366.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1148.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.41,1457.93,
STRYKER ORT HUMERAL COMPON 5351-4106,2111581,CDM,278,RC,,,both,,,7409.22,4445.53,,5556.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5556.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1578.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1578.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4815.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1592.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5927.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5556.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5556.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5556.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5556.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1518.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4667.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1518.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1518.15,5927.38,
STRYKER ORT HUMERAL COMPON 5351-4106,2112646,CDM,278,RC,,,both,,,5019.22,3011.53,,3764.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3764.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1069.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1069.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3262.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1079.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4015.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3764.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3764.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3764.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3764.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1028.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3162.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1028.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1028.44,4015.38,
STRYKER ORT HUMERAL COMPON 5351-4107,2111518,CDM,278,RC,,,both,,,4880.78,2928.47,,3660.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3660.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1039.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1039.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3172.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1049.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3904.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3660.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3660.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3660.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3660.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3074.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1000.07,3904.62,
STRYKER ORT HUMERAL HEAD 5350-4518,2111517,CDM,278,RC,,,both,,,2485.47,1491.28,,1864.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1864.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,529.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1615.56,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,534.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1988.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1864.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1864.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1565.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.27,1988.38,
STRYKER ORT HUMERAL HEAD 5350-4518,2111582,CDM,278,RC,,,both,,,2192.56,1315.54,,1644.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1644.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,467.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,467.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1425.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,471.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1754.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1644.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1644.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1644.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1644.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1381.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.26,1754.05,
STRYKER ORT HUMERAL NAIL 1830-0919S,2111923,CDM,278,RC,,,both,,,3187.79,1912.67,,2390.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2390.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,679,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,679,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2072.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,685.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2550.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2390.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2390.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2390.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2390.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,653.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2008.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,653.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,653.18,2550.23,
STRYKER ORT K WIRE 02712106450SOP,2111682,CDM,278,RC,C1713,HCPCS,both,,,285.06,171.04,,213.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,213.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.29,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,61.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,213.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,179.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.41,228.05,
STRYKER ORT K WIRE 1806-0050S,2111549,CDM,278,RC,C1713,HCPCS,both,,,199.98,119.99,,149.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,149.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,149.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.98,159.98,
STRYKER ORT L IPP TIB INSERT 6742-4-116,2111632,CDM,278,RC,C1776,HCPCS,both,,,3152.36,1891.42,,2364.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2364.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,671.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,671.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2049.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,677.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2521.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2364.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2364.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2364.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2364.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1985.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,645.92,2521.89,
STRYKER ORT L IPP TIB INSERT 6742-4-119,2112720,CDM,278,RC,C1776,HCPCS,both,,,2004.88,1202.93,,1503.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1503.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1303.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,431.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1603.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1503.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1503.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1503.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1503.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1263.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.8,1603.9,
STRYKER ORT LAG SCREW 02730600080SON,2111511,CDM,278,RC,,,both,,,937.52,562.51,,703.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,703.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,609.39,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,703.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,590.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.1,750.02,
STRYKER ORT LAG SCREW 02730600085SOS,2111550,CDM,278,RC,,,both,,,937.52,562.51,,703.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,703.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,609.39,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,703.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,590.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.1,750.02,
STRYKER ORT LAG SCREW 3080-0085S,2111750,CDM,278,RC,,,both,,,1159.35,695.61,,869.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,869.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,246.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,753.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,249.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,927.48,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,869.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,869.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,869.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,869.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,730.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.55,927.48,
STRYKER ORT MAX NA HIP STEM,2111887,CDM,278,RC,C1776,HCPCS,both,,,4905.7,2943.42,,3679.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3679.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1044.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1044.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3188.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1054.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3924.56,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3679.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3679.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3679.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3679.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1005.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3090.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1005.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1005.18,3924.56,
STRYKER ORT MAX NA HIP STEM 6051-0935S,2111886,CDM,278,RC,C1776,HCPCS,both,,,3474.45,2084.67,,2605.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2605.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,740.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,740.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2258.39,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,747.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2779.56,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2605.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2605.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2605.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2605.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,711.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2188.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,711.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,711.91,2779.56,
STRYKER ORT MAX NE HIP STEM 6051-0730S,2112073,CDM,278,RC,C1776,HCPCS,both,,,3373.24,2023.94,,2529.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2529.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,718.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2192.61,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,725.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2698.59,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2529.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2529.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2529.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2529.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2125.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.18,2698.59,
STRYKER ORT MAX NE HIP STEM 6052-1035S,2111969,CDM,278,RC,C1776,HCPCS,both,,,5801.54,3480.92,,4351.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4351.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1235.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1235.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3771,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1247.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4641.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4351.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4351.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4351.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4351.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1188.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3654.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1188.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1188.74,4641.23,
STRYKER ORT MAX NE HIP STEM 6052-1240S,2112024,CDM,278,RC,C1776,HCPCS,both,,,3373.24,2023.94,,2529.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2529.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,718.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2192.61,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,725.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2698.59,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2529.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2529.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2529.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2529.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2125.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,691.18,2698.59,
STRYKER ORT MAX NE HIP STEM 6052-1240S,2112049,CDM,278,RC,C1776,HCPCS,both,,,11023.6,6614.16,,8267.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,8267.7,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2348.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2348.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7165.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2370.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8818.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,8267.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8267.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8267.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8267.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2258.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6944.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2258.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2258.74,8818.88,
STRYKER ORT MED UNIV CEMENT 6M7800,2111722,CDM,278,RC,,,both,,,540,324,,405,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,405,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,351,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,116.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,432,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,340.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.65,432,
STRYKER ORT MOD ROT HING KNEE 6481-2-133,2111733,CDM,278,RC,C1776,HCPCS,both,,,1121.27,672.76,,840.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,840.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,238.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,728.83,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,241.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,897.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,840.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,840.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,706.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.75,897.02,
STRYKER ORT MRH KNEE TIB B P 6481-3-110,2111724,CDM,278,RC,C1713,HCPCS,both,,,5059.11,3035.47,,3794.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3794.33,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1077.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1077.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3288.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1087.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4047.29,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3794.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3794.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3794.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3794.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1036.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3187.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1036.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1036.61,4047.29,
STRYKER ORT MRH KNEE TIB SLEE 6481-2-140,2111729,CDM,278,RC,C1776,HCPCS,both,,,938.05,562.83,,703.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,703.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,609.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,750.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,703.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,703.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,590.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.21,750.44,
STRYKER ORT MRH TIB ROT COMP 6481-2-100,2111727,CDM,278,RC,C1776,HCPCS,both,,,4076.94,2446.16,,3057.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3057.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,868.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,868.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2650.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,876.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3261.55,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3057.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3057.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3057.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3057.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,835.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2568.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,835.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,835.37,3261.55,
STRYKER ORT NAIL 0731251180SOR,2111510,CDM,278,RC,,,both,,,2756.75,1654.05,,2067.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2067.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,587.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,587.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1791.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,592.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2205.4,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2067.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2067.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2067.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2067.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1736.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.86,2205.4,
STRYKER ORT NAIL 3125-1180S,2112823,CDM,278,RC,,,both,,,1290.8,774.48,,968.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,968.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,274.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,274.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,839.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,277.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1032.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,968.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,968.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,968.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,968.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,813.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.48,1032.64,
STRYKER ORT NAIL KIT 3325-0300S,2111917,CDM,278,RC,,,both,,,4302.59,2581.55,,3226.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3226.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,916.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2796.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,925.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3442.07,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3226.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3226.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2710.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.6,3442.07,
STRYKER ORT POLYETHY INSERT 623-00-36E,2111689,CDM,278,RC,C1776,HCPCS,both,,,1688.53,1013.12,,1266.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1266.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,359.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1097.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,363.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1350.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1266.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1266.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1063.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,345.98,1350.82,
STRYKER ORT POS STABILIZED FEMORAL 5515-,2112681,CDM,278,RC,C1776,HCPCS,both,,,2681.91,1609.15,,2011.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2011.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,571.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,571.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1743.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,576.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2145.53,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2011.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1689.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.52,2145.53,
STRYKER ORT PTOX HUMERAL NAIL 1832-1045S,2112465,CDM,278,RC,,,both,,,6365.94,3819.56,,4774.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4774.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1355.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1355.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4137.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1368.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5092.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4774.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4774.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4774.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4774.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1304.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4010.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1304.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1304.38,5092.75,
STRYKER ORT REVISION,2111482,CDM,278,RC,C1776,HCPCS,both,,,4886.72,2932.03,,3665.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3665.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1040.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1040.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3176.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1050.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3909.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3665.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3665.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3665.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3665.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3078.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.29,3909.38,
STRYKER ORT SCREW CANN 4.0 34524/18/50,2111611,CDM,278,RC,,,both,,,118.72,71.23,,89.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,89.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,25.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.33,94.98,
STRYKER ORT SCREW CANN 6.5 32680,2111484,CDM,278,RC,,,both,,,469.76,281.86,,352.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,352.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,305.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,101,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,352.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,295.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.25,375.81,
STRYKER ORT STAB FEM COMP 5512-F-201,2112186,CDM,278,RC,C1776,HCPCS,both,,,12006.52,7203.91,,9004.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,9004.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2557.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2557.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7804.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2581.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9605.22,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,9004.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9004.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9004.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9004.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2460.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7564.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2460.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2460.14,9605.22,
STRYKER ORT STAB FEM COMP 5512-F-401,2111625,CDM,278,RC,C1776,HCPCS,both,,,4664.04,2798.42,,3498.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3498.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,993.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,993.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3031.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1002.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3731.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3498.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3498.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3498.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3498.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,955.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2938.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,955.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,955.66,3731.23,
STRYKER ORT STABLE FEMORA 5515-F-401,2112170,CDM,278,RC,C1776,HCPCS,both,,,3132.1,1879.26,,2349.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2349.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,667.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2035.87,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,673.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2505.68,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2349.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1973.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.77,2505.68,
STRYKER ORT STEM EXTENDER,2112499,CDM,278,RC,C1776,HCPCS,both,,,2178.56,1307.14,,1633.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1633.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,464.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,464.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1416.06,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,468.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1742.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1633.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1372.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.39,1742.85,
STRYKER ORT STEM EXTENDER 5571-S-050,2111624,CDM,278,RC,C1776,HCPCS,both,,,2166.57,1299.94,,1624.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1624.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,461.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1408.27,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,465.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1733.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1624.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1624.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1624.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1624.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1364.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.93,1733.26,
STRYKER ORT STEM EXTENDER 6630-6-110,2111726,CDM,278,RC,C1713,HCPCS,both,,,1493.32,895.99,,1119.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1119.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,318.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,318.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,970.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,321.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1194.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1119.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1119.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1119.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1119.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,940.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.98,1194.66,
STRYKER ORT STR CEM STEM 6485-3-113,2111723,CDM,278,RC,C1776,HCPCS,both,,,4473.82,2684.29,,3355.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3355.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,952.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,952.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2907.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,961.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3579.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3355.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3355.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3355.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3355.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2818.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.69,3579.06,
STRYKER ORT SUPRAC NAIL 02718261220S0S,2111763,CDM,278,RC,,,both,,,4177.61,2506.57,,3133.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3133.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,889.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,889.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2715.45,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,898.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3342.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3133.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3133.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3133.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3133.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2631.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,855.99,3342.09,
STRYKER ORT TIB BASEPLATE 5521-B-400,2112169,CDM,278,RC,,,both,,,2613.42,1568.05,,1960.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1960.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,556.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,556.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1698.72,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,561.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2090.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1960.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1960.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1960.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1960.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,535.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1646.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,535.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,535.49,2090.74,
STRYKER ORT TIB INSERT PS 5532-G-416,2111577,CDM,278,RC,C1776,HCPCS,both,,,1731.81,1039.09,,1298.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1298.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,368.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1125.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,372.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1385.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1298.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1298.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1298.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1298.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1091.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.85,1385.45,
STRYKER ORT TIB NAIL,2111947,CDM,278,RC,,,both,,,3134,1880.4,,2350.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2350.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,667.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2037.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,673.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2507.2,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2350.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2350.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2350.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2350.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,642.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1974.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,642.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,642.16,2507.2,
STRYKER ORT TIB NAIL 1822-1039S,2111533,CDM,278,RC,,,both,,,3169.01,1901.41,,2376.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2376.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,675,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,675,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2059.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,681.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2535.21,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2376.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2376.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2376.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2376.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,649.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1996.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,649.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,649.33,2535.21,
STRYKER ORT TIB NAIL 1822-1231S,2111981,CDM,278,RC,,,both,,,3130.93,1878.56,,2348.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2348.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,666.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,666.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2035.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,673.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2504.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2348.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2348.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2348.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2348.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1972.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.53,2504.74,
STRYKER ORT TIBIAL BEAR INS 5532-G-419,2112100,CDM,278,RC,C1776,HCPCS,both,,,2462.45,1477.47,,1846.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1846.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,524.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1600.59,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,529.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1969.96,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1846.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1846.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1846.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1846.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1551.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,504.56,1969.96,
STRYKER ORT TRI AS PAT,2112667,CDM,278,RC,C1776,HCPCS,both,,,2236.27,1341.76,,1677.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1677.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,476.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,476.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1453.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,480.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1789.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1408.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,1789.02,
STRYKER ORT TRI AS PAT 5551-G-299,2112782,CDM,278,RC,C1776,HCPCS,both,,,2236.27,1341.76,,1677.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1677.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,476.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,476.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1453.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,480.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1789.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1677.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1408.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.21,1789.02,
STRYKER ORT TRI AS PAT 5551-G-320,2112084,CDM,278,RC,C1776,HCPCS,both,,,2642.49,1585.49,,1981.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1981.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,562.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,562.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1717.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,568.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2113.99,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1981.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1981.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1981.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1981.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,541.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1664.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,541.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,541.45,2113.99,
STRYKER ORT TRI AS PAT 5551-G-320,2112091,CDM,278,RC,C1776,HCPCS,both,,,1231.7,739.02,,923.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,923.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,262.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,800.61,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,264.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,985.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,923.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,923.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,923.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,923.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,775.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.38,985.36,
STRYKER ORT TRI AS PAT 5551-L-320,2112015,CDM,278,RC,C1776,HCPCS,both,,,1913.54,1148.12,,1435.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1435.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,407.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1243.8,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,411.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1530.83,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1435.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1205.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,392.08,1530.83,
STRYKER ORT TRI AS PAT CAP5551-G-320,2111530,CDM,278,RC,C1776,HCPCS,both,,,1127.42,676.45,,845.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,845.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,732.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,242.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,901.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,845.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,845.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,710.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.01,901.94,
STRYKER ORT TRI ASYM PAT REVI 5551-G-381,2111677,CDM,278,RC,C1776,HCPCS,both,,,2394.24,1436.54,,1795.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1795.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,509.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,509.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1556.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,514.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1915.39,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1508.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.58,1915.39,
STRYKER ORT TRI ASYM PATEL 5520-B-600,2112239,CDM,278,RC,C1776,HCPCS,both,,,1949.43,1169.66,,1462.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1462.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,415.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,415.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1267.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,419.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1559.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1462.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1462.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1228.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.44,1559.54,
STRYKER ORT TRI ASYM PATEL 5551-G-350,2111631,CDM,278,RC,C1776,HCPCS,both,,,2930.31,1758.19,,2197.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2197.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,624.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,624.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1904.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,630.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2344.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2197.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1846.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600.42,2344.25,
STRYKER ORT TRI ASYM PATEL CAP5551-G-350,2111479,CDM,278,RC,C1776,HCPCS,both,,,1972.92,1183.75,,1479.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1479.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,420.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1282.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,424.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1578.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1479.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1479.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1479.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1479.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1242.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,404.25,1578.34,
STRYKER ORT TRI ASYM PATELLA 5551-G-299,2111483,CDM,278,RC,C1776,HCPCS,both,,,2349.47,1409.68,,1762.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1762.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,500.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,500.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1527.16,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,505.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1879.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1762.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1762.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1762.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1762.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,481.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1480.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,481.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,481.41,1879.58,
STRYKER ORT TRI ASYM PATELLA 5551-G-381,2111490,CDM,278,RC,C1776,HCPCS,both,,,906.69,544.01,,680.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,680.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,193.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,193.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,589.35,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,194.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,725.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,680.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,680.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,571.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.78,725.35,
STRYKER ORT TRI ASYM PATELLS 5551-G-401,2111504,CDM,278,RC,C1776,HCPCS,both,,,1067.32,640.39,,800.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,800.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,693.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,229.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,853.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,800.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,672.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.69,853.86,
STRYKER ORT TRI ASYM PATELLS 5551-G-401,2111980,CDM,278,RC,C1776,HCPCS,both,,,2418.21,1450.93,,1813.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1813.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,515.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,515.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1571.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,519.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1934.57,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1813.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1813.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1813.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1813.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1523.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495.49,1934.57,
STRYKER ORT TRI ASYM PATELLS W/ANTI,2113040,CDM,278,RC,C1776,HCPCS,both,,,2215.23,1329.14,,1661.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1661.42,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,471.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,471.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1439.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,476.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1772.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1661.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1661.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1661.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1661.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,453.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1395.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,453.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,453.9,1772.18,
STRYKER ORT TRI OFFSET ADAPTER,2113181,CDM,278,RC,C1776,HCPCS,both,,,2789.74,1673.84,,2092.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2092.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,594.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,594.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1813.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,599.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2231.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2092.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2092.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2092.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2092.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,571.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1757.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,571.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,571.62,2231.79,
STRYKER ORT TRI STABLE FEMORA 5512-F301,2112631,CDM,278,RC,C1776,HCPCS,both,,,13027.43,7816.46,,9770.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,9770.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2774.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2774.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8467.83,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,2800.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10421.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,9770.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9770.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9770.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9770.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2669.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8207.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2669.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2669.32,10421.94,
STRYKER ORT TRI STABLE FEMORA 5515-F-201,2112083,CDM,278,RC,C1776,HCPCS,both,,,7079.81,4247.89,,5309.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5309.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1508,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1508,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4601.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1522.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5663.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5309.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5309.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5309.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5309.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1450.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4460.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1450.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1450.65,5663.85,
STRYKER ORT TRI STABLE FEMORA 5515-F-201,2112090,CDM,278,RC,C1776,HCPCS,both,,,4839.83,2903.9,,3629.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3629.87,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1030.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1030.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3145.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1040.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3871.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3629.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3629.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3629.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3629.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,991.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3049.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,991.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,991.68,3871.86,
STRYKER ORT TRI STABLE FEMORA 5515-F-202,2112910,CDM,278,RC,C1776,HCPCS,both,,,3018.38,1811.03,,2263.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2263.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,642.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,642.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1961.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,648.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2414.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2263.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2263.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2263.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2263.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1901.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,618.47,2414.7,
STRYKER ORT TRI STABLE FEMORA 5515-F-301,2111531,CDM,278,RC,C1776,HCPCS,both,,,2930.59,1758.35,,2197.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2197.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,624.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,624.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1904.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,630.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2344.47,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2197.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1846.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,600.48,2344.47,
STRYKER ORT TRI STABLE FEMORA 5515-F-301,2112653,CDM,278,RC,C1776,HCPCS,both,,,3271.39,1962.83,,2453.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2453.54,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,696.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2126.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,703.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2617.11,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2453.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2453.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,670.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2060.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,670.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,670.31,2617.11,
STRYKER ORT TRI STABLE FEMORA 5515-F-302,2111580,CDM,278,RC,C1776,HCPCS,both,,,15064.13,9038.48,,11298.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,11298.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3208.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3208.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9791.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,3238.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12051.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,11298.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11298.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11298.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11298.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3086.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9490.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3086.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3086.64,12051.3,
STRYKER ORT TRI STABLE FEMORA 5515-F-401,2111480,CDM,278,RC,C1776,HCPCS,both,,,6490.94,3894.56,,4868.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4868.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1382.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1382.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4219.11,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1395.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5192.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4868.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4868.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4868.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4868.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1329.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4089.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1329.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1329.99,5192.75,
STRYKER ORT TRI STABLE FEMORA 5515-F-401,2112098,CDM,278,RC,C1776,HCPCS,both,,,3574.17,2144.5,,2680.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2680.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,761.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,761.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2323.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,768.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2859.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2680.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2251.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,732.35,2859.34,
STRYKER ORT TRI STABLE FEMORA 5515-F-501,2111488,CDM,278,RC,C1776,HCPCS,both,,,3645.06,2187.04,,2733.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2733.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,776.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,776.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2369.29,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,783.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2916.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2733.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2733.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2733.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2733.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2296.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.87,2916.05,
STRYKER ORT TRI STABLE FEMORA 5515-F-502,2111543,CDM,278,RC,C1776,HCPCS,both,,,3645.06,2187.04,,2733.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2733.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,776.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,776.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2369.29,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,783.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2916.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2733.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2733.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2733.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2733.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2296.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,746.87,2916.05,
STRYKER ORT TRI STABLE FEMORA 5515-F-601,2111509,CDM,278,RC,C1776,HCPCS,both,,,2943.58,1766.15,,2207.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2207.69,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,626.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,626.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1913.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,632.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2354.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2207.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2207.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1854.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,603.14,2354.86,
STRYKER ORT TRI STABLE FEMORA W/ANTIB,2113037,CDM,278,RC,C1776,HCPCS,both,,,6485.61,3891.37,,4864.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4864.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1381.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1381.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4215.65,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1394.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5188.49,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4864.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4864.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4864.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4864.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1328.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4085.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1328.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1328.9,5188.49,
STRYKER ORT TRI STABLE FEMRA,2113180,CDM,278,RC,C1776,HCPCS,both,,,15516.06,9309.64,,11637.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,11637.05,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3304.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3304.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10085.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,3335.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12412.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,11637.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11637.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11637.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11637.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3179.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9775.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3179.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3179.24,12412.85,
STRYKER ORT TRI TIB BASEPLATE 5520-B-400,2111544,CDM,278,RC,,,both,,,1000.75,600.45,,750.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,750.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,213.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,650.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,215.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,800.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,750.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,630.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.05,800.6,
STRYKER ORT TRI TIB BASEPLATE 5520-B-400,2112097,CDM,278,RC,,,both,,,2007.89,1204.73,,1505.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1505.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1305.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,431.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1606.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1505.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1505.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1505.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1505.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1264.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.42,1606.31,
STRYKER ORT TRI TIB BASEPLATE 5520-B-400,2112099,CDM,278,RC,,,both,,,2112.67,1267.6,,1584.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1584.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,450,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,450,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1373.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,454.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1690.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1584.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1584.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1584.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1584.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,432.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1330.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,432.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,432.89,1690.14,
STRYKER ORT TRI TIB BASEPLATE 5520-B-500,2111487,CDM,278,RC,,,both,,,2148.02,1288.81,,1611.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1611.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,457.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1396.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,461.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1718.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1611.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1611.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1611.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1611.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1353.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.13,1718.42,
STRYKER ORT TRI TIB BASEPLATE 5520-B-500,2111920,CDM,278,RC,,,both,,,2007.89,1204.73,,1505.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1505.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1305.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,431.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1606.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1505.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1505.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1505.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1505.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1264.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.42,1606.31,
STRYKER ORT TRI TIB BASEPLATE 5521-B-200,2112086,CDM,278,RC,,,both,,,5870.7,3522.42,,4403.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4403.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1250.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1250.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3815.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1262.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4696.56,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4403.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4403.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4403.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4403.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1202.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3698.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1202.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1202.91,4696.56,
STRYKER ORT TRI TIB BASEPLATE 5521-B-200,2112095,CDM,278,RC,,,both,,,4013.7,2408.22,,3010.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3010.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,854.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2608.91,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,862.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3210.96,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3010.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3010.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3010.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3010.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,822.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2528.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,822.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,822.41,3210.96,
STRYKER ORT TRI TIB BASEPLATE 5521-B-200,2112408,CDM,278,RC,,,both,,,1892.33,1135.4,,1419.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1419.25,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,403.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,403.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1230.01,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,406.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1513.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1419.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1419.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1419.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1419.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1192.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,387.74,1513.86,
STRYKER ORT TRI TIB BASEPLATE 5521-B-300,2112644,CDM,278,RC,,,both,,,3386.18,2031.71,,2539.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2539.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,721.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,721.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2201.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,728.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2708.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2539.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2539.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2539.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2539.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2133.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,693.83,2708.94,
STRYKER ORT TRI TIB BASEPLATE 5521-B-300,2112697,CDM,278,RC,,,both,,,1829.5,1097.7,,1372.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1372.13,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,389.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,389.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1189.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,393.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1463.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1372.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1372.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1152.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,374.86,1463.6,
STRYKER ORT TRI TIB BASEPLATE 5521-B-400,2111826,CDM,278,RC,,,both,,,5702.95,3421.77,,4277.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4277.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1214.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1214.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3706.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1226.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4562.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4277.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4277.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4277.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4277.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1168.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3592.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1168.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1168.53,4562.36,
STRYKER ORT TRI TIB BASEPLATE W/ANTI,2113038,CDM,278,RC,,,both,,,3833.29,2299.97,,2874.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2874.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,816.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,816.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2491.64,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,824.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3066.63,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2874.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2874.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2874.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2874.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,785.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2414.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,785.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,785.44,3066.63,
STRYKER ORT TRI TIB BPLATE CAP5520-B-300,2111481,CDM,278,RC,,,both,,,2470.93,1482.56,,1853.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1853.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,526.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1606.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,531.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1976.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1853.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1853.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1556.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.29,1976.74,
STRYKER ORT TRI TIB BPLATE CAP5520-B-300,2112652,CDM,278,RC,,,both,,,1932.96,1159.78,,1449.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1449.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,411.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1256.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,415.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1546.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1449.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1449.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1449.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1449.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396.06,1546.37,
STRYKER ORT TRI TIB INSE 5532-G-313,2111995,CDM,278,RC,C1776,HCPCS,both,,,5033.23,3019.94,,3774.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3774.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1072.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1072.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3271.6,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1082.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4026.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3774.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3774.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3774.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3774.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1031.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3170.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1031.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1031.31,4026.58,
STRYKER ORT TRI TIB INSE 5532-G-313,2112668,CDM,278,RC,C1776,HCPCS,both,,,4511.05,2706.63,,3383.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3383.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,960.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,960.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2932.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,969.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3608.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3383.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3383.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2841.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,924.31,3608.84,
STRYKER ORT TRI TIB INSE CA P 5532-G-313,2111569,CDM,278,RC,C1776,HCPCS,both,,,2439.51,1463.71,,1829.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1829.63,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,519.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1585.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,524.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1951.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1829.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1829.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1829.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1829.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1536.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.86,1951.61,
STRYKER ORT TRI TIB INSERT,2112469,CDM,278,RC,C1776,HCPCS,both,,,1847.36,1108.42,,1385.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1385.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,393.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,393.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1200.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,397.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1477.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1385.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1385.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1385.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1385.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1163.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,378.52,1477.89,
STRYKER ORT TRI TIB INSERT 5532-G-309,2112224,CDM,278,RC,C1776,HCPCS,both,,,4876.54,2925.92,,3657.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3657.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1038.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1038.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3169.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1048.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3901.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3657.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3657.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3657.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3657.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3072.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,999.2,3901.23,
STRYKER ORT TRI TIB INSERT 5532-G-316,2111478,CDM,278,RC,C1776,HCPCS,both,,,2271.78,1363.07,,1703.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1703.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,483.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,483.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1476.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,488.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1817.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1703.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1703.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1431.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.49,1817.42,
STRYKER ORT TRI TIB INSERT 5532-G-316,2112654,CDM,278,RC,C1776,HCPCS,both,,,2253.57,1352.14,,1690.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1690.18,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,480.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1464.82,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,484.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1802.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1690.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1419.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.76,1802.86,
STRYKER ORT TRI TIB INSERT 5532-G-413,2112407,CDM,278,RC,C1776,HCPCS,both,,,2205.94,1323.56,,1654.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1654.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,469.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,469.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1433.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,474.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1764.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1654.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1654.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1654.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1654.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1389.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452,1764.75,
STRYKER ORT TRI TIB INSERT 5532-G-511,2111505,CDM,278,RC,C1776,HCPCS,both,,,1970.83,1182.5,,1478.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1478.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,419.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1281.04,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,423.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1576.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1478.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1478.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1478.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1478.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,403.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1241.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,403.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,403.82,1576.66,
STRYKER ORT TRI TIB INSERT 5532-G-513,2111489,CDM,278,RC,C1776,HCPCS,both,,,4470.63,2682.38,,3352.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3352.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,952.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,952.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2905.91,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,961.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3576.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3352.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3352.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3352.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3352.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2816.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,916.03,3576.5,
STRYKER ORT TRI TIB INSERT 5532-G-516,2112560,CDM,278,RC,C1776,HCPCS,both,,,4160.88,2496.53,,3120.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3120.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,886.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,886.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2704.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,894.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3328.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3120.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3120.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3120.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3120.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,852.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2621.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,852.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,852.56,3328.7,
STRYKER ORT TRI TIB INSERT 5532-G-519,2111529,CDM,278,RC,C1776,HCPCS,both,,,2340.08,1404.05,,1755.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1755.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,498.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,498.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1521.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,503.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1872.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1755.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1755.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1755.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1755.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,479.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1474.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,479.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,479.48,1872.06,
STRYKER ORT TRI TIB INSERT W/ANTI,2113039,CDM,278,RC,C1776,HCPCS,both,,,7210.94,4326.56,,5408.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5408.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1535.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1535.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4687.11,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1550.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5768.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5408.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5408.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5408.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5408.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1477.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4542.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1477.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1477.52,5768.75,
STRYKER ORT TRID POLY INSERT 623-00-36E,2111664,CDM,278,RC,C1776,HCPCS,both,,,1966.36,1179.82,,1474.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1474.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,418.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1278.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,422.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1573.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1474.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1474.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1474.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1474.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1238.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.91,1573.09,
STRYKER ORT TRID POLY INSERT 623-00-36G,2111613,CDM,278,RC,C1776,HCPCS,both,,,1966.36,1179.82,,1474.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1474.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,418.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,418.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1278.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,422.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1573.09,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1474.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1474.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1474.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1474.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1238.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,402.91,1573.09,
STRYKER ORT TRID POLY INSERT 623-00-36G,2112047,CDM,278,RC,C1776,HCPCS,both,,,3816.16,2289.7,,2862.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2862.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,812.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,812.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2480.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,820.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3052.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2862.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2862.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2862.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2862.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,781.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2404.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,781.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,781.93,3052.93,
STRYKER ORT TRID POLY INSERT 723-00-36F,2113221,CDM,278,RC,C1776,HCPCS,both,,,1501.48,900.89,,1126.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1126.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,319.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,975.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,322.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1201.18,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1126.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1126.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1126.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1126.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,307.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,945.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,307.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,307.65,1201.18,
STRYKER ORT UNI CONS ACET INS 6302-N-428,2111536,CDM,278,RC,,,both,,,1815.62,1089.37,,1361.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1361.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,386.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,386.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1180.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,390.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1452.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1361.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1361.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1143.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.02,1452.5,
STRYKER ORT UNIV CEM RESTRICTOR,2111970,CDM,278,RC,,,both,,,204.65,122.79,,153.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,153.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,153.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,163.72,
STRYKER ORT UNIV DIS CEM SPAC 1067-0010,2111832,CDM,278,RC,,,both,,,318.35,191.01,,238.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,238.76,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,206.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,68.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.68,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,238.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,200.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.23,254.68,
STRYKER ORT UNIV HEAD BIPOLAR UH1-47-26,2111555,CDM,278,RC,C1776,HCPCS,both,,,1574.69,944.81,,1181.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1181.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,335.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1023.55,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,338.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1259.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1181.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1181.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1181.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1181.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,992.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,322.65,1259.75,
STRYKER ORT UNIV HEAD BIPOLAR UH1-47-26,2111884,CDM,278,RC,C1776,HCPCS,both,,,898.58,539.15,,673.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,673.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,584.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,193.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,673.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.12,718.86,
STRYKER ORT UNIV HEAD BIPOLAR UH1-56-26,2112023,CDM,278,RC,C1776,HCPCS,both,,,872.38,523.43,,654.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,654.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,567.05,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,187.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,697.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,654.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,549.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.75,697.9,
STRYKER ORT UNIVERSAL HEAD UH1-44-26,2111997,CDM,278,RC,C1776,HCPCS,both,,,1484.3,890.58,,1113.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1113.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,316.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,316.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,964.8,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,319.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1187.44,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1113.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,935.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.13,1187.44,
STRYKER ORT UNIVERSAL HEAD UH1-44-26,2112075,CDM,278,RC,C1776,HCPCS,both,,,763.43,458.06,,572.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,572.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,162.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,164.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,610.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,572.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,572.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,572.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,572.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,480.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.43,610.74,
STRYKER ORT UNIVERSAL HEAD UH1-52-26,2111564,CDM,278,RC,C1776,HCPCS,both,,,2284.66,1370.8,,1713.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1713.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,486.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,486.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1485.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,491.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1827.73,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1713.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1439.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,468.13,1827.73,
STRYKER ORT UNIVERSAL HEAD UH1-53-26,2111609,CDM,278,RC,C1776,HCPCS,both,,,2153.52,1292.11,,1615.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1615.14,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,458.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1399.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,463.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1722.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1615.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1615.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1615.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1615.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1356.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,441.26,1722.82,
STRYKER ORT UNIVERSAL HEAD UH1-54-26,2111572,CDM,278,RC,C1776,HCPCS,both,,,2218.12,1330.87,,1663.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1663.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,472.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1441.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,476.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1774.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1397.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,1774.5,
STRYKER ORT UNIVERSAL HEAD UH1-54-26,2113110,CDM,278,RC,C1776,HCPCS,both,,,2218.12,1330.87,,1663.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1663.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,472.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,472.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1441.78,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,476.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1774.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1663.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1397.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.49,1774.5,
STRYKER ORTC-TAPER ION HEAD 06-2800,2112492,CDM,278,RC,C1776,HCPCS,both,,,1067.87,640.72,,800.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,800.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,694.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,229.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,800.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,800.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,672.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,218.81,854.3,
STRYKER ORTC-TAPER ION HEAD 06-2810,2111690,CDM,278,RC,C1776,HCPCS,both,,,1655.76,993.46,,1241.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1241.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,352.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,352.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1076.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,355.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1324.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1241.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1241.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1043.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.27,1324.61,
STRYKER ORTC-TAPER ION HEAD 06-3600,2112614,CDM,278,RC,C1776,HCPCS,both,,,2253.99,1352.39,,1690.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1690.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,480.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,480.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1465.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,484.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1803.19,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1690.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1690.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1420.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,461.84,1803.19,
STRYKER PERIPHERAL SCREW,2112710,CDM,278,RC,,,both,,,405.68,243.41,,304.26,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,304.26,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,263.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,87.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,324.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,304.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,255.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.12,324.54,
STRYKER S S BEADED CABLE SET 2.0,2109923,CDM,278,RC,,,both,,,959.69,575.81,,719.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,719.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,204.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,623.8,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,206.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,767.75,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,719.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,719.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,719.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,719.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,604.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.64,767.75,
STRYKER SCREW CROSS PIN 2.3X12MM LOCKING,2112837,CDM,278,RC,,,both,,,248.32,148.99,,186.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,186.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,161.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,53.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,198.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.88,198.66,
STRYKER SLEEVE ONLY 1.6,2109924,CDM,278,RC,,,both,,,385.43,231.26,,289.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,289.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,250.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,82.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,289.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,242.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.97,308.34,
STRYKER SLEEVE ONLY 2.0,2109925,CDM,278,RC,,,both,,,385.43,231.26,,289.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,289.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,250.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,82.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,289.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,242.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.97,308.34,
STRYKER SS SLEEVE ONLY 2.0,2109926,CDM,278,RC,,,both,,,383.94,230.36,,287.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,287.96,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,249.56,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,82.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,307.15,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,287.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,241.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.67,307.15,
STRYKER WASHER 5.0 390017,2110422,CDM,278,RC,C1713,HCPCS,both,,,257.07,154.24,,192.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,192.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,167.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,55.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,161.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,205.66,
SUPERPUBIC BANANNO CATH 8289,2101626,CDM,278,RC,C2627,HCPCS,both,,,460.04,276.02,,345.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,345.03,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,299.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,98.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.03,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,345.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,289.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.26,368.03,
SYNTHES 8 GUAGE DEL NEEDLE DLS-7083-01S,2112633,CDM,278,RC,,,both,,,134.52,80.71,,100.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,100.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,28.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.56,107.62,
SYNTHES ADJ LG FIXATOR 392.961,2111225,CDM,278,RC,,,both,,,7303.02,4381.81,,5477.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5477.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1555.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1555.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4746.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1570.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5842.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5477.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5477.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5477.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5477.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1496.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4600.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1496.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1496.39,5842.42,
SYNTHES CALIB DRILL BIT 03.010.061,2111052,CDM,278,RC,,,both,,,421.18,252.71,,315.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,315.89,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,273.77,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,90.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,265.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.3,336.94,
SYNTHES CANNULATED SCREW,2112578,CDM,278,RC,,,both,,,443.03,265.82,,332.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,332.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,287.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,95.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,332.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,279.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.78,354.42,
SYNTHES CLAV PLATE 3.5 8 HOLE 02.112.030,2111500,CDM,278,RC,,,both,,,3656.71,2194.03,,2742.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2742.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,778.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,778.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2376.86,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,786.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2925.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2742.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2742.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2742.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2742.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,749.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2303.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,749.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,749.26,2925.37,
SYNTHES CORT SCREWS 204.840/845/850,2111498,CDM,278,RC,,,both,,,103.01,61.81,,77.26,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,77.26,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,22.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.11,82.41,
SYNTHES CORTEX SCREW,2112580,CDM,278,RC,,,both,,,103.87,62.32,,77.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,77.9,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,22.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,77.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.28,83.1,
SYNTHES CORTICAL SCREW,2112579,CDM,278,RC,,,both,,,422.98,253.79,,317.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,317.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,274.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,90.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,317.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.67,338.38,
SYNTHES DRILL BIT 03.113.023/024,2112636,CDM,278,RC,,,both,,,264.91,158.95,,198.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,198.68,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,172.19,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,56.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,198.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.28,211.93,
SYNTHES DRILL TIP GUIDE WIRE,2112581,CDM,278,RC,,,both,,,175.89,105.53,,131.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,131.92,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,37.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.71,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,131.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,110.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.04,140.71,
SYNTHES DRILLABLE PUTTY 5CC,2112561,CDM,278,RC,,,both,,,2949.94,1769.96,,2212.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2212.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,628.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,628.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1917.46,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,634.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2359.95,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2212.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2212.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2212.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2212.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,604.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1858.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,604.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,604.44,2359.95,
SYNTHES EX TIBIAL NAIL 04.034.446S,2111049,CDM,278,RC,,,both,,,2697.55,1618.53,,2023.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2023.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,574.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,574.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1753.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,579.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2158.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2023.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2023.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2023.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2023.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1699.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,552.73,2158.04,
SYNTHES K WIRE 292.71,2112604,CDM,278,RC,,,both,,,404.74,242.84,,303.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,303.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,263.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,87.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,323.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,303.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,303.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,254.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.93,323.79,
SYNTHES LOCKING SCREW,2111050,CDM,278,RC,,,both,,,443.03,265.82,,332.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,332.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,287.97,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,95.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,354.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,332.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,279.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.78,354.42,
SYNTHES MEDIAL PROX TIBIA PLATE 239-959S,2112457,CDM,278,RC,,,both,,,3943.26,2365.96,,2957.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2957.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,839.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,839.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2563.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,847.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3154.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2957.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2957.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2957.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2957.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,807.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2484.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,807.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,807.97,3154.61,
SYNTHES NEEDLE POINT 03.010.104,2111053,CDM,278,RC,,,both,,,293.55,176.13,,220.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,220.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,190.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,63.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,184.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,234.84,
SYNTHES NORIAN PUTTY 10CC 07.704.010S,2112634,CDM,278,RC,,,both,,,5628.82,3377.29,,4221.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4221.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1198.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1198.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3658.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1210.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4503.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4221.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4221.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4221.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4221.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1153.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3546.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1153.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1153.35,4503.06,
SYNTHES OBLIQUE T PLATE RIGHT 241-051,2112670,CDM,278,RC,,,both,,,911.63,546.98,,683.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,683.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,592.56,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,196,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,729.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,683.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,574.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,186.79,729.3,
SYNTHES PROX TIBIA PLATE 02.127.230S,2112635,CDM,278,RC,,,both,,,3852.87,2311.72,,2889.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2889.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,820.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,820.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2504.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,828.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3082.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2889.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2889.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2889.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2889.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2427.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,789.45,3082.3,
SYNTHES REAMING ROD 351.706S,2111051,CDM,278,RC,,,both,,,211.54,126.92,,158.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,158.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,45.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,158.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,133.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.34,169.23,
SYNTHES SCHANZ SCREWS 294.785,2111224,CDM,278,RC,,,both,,,295.35,177.21,,221.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,221.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,63.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,236.28,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,221.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,186.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.52,236.28,
SYNTHES VA LOCK SCREW 3.5 02.127.180/16,2112637,CDM,278,RC,,,both,,,388.73,233.24,,291.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,291.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,252.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,244.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.65,310.98,
TRI CORTICAL BONE GRAFT,2111758,CDM,278,RC,C1762,HCPCS,both,,,2681.74,1609.04,,2011.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2011.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,571.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,571.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1743.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,576.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2145.39,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2011.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2011.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1689.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,549.49,2145.39,
US IMPLANT 3.5 CANCELLOUS SCREW 37352-18,2111252,CDM,278,RC,,,both,,,350.31,210.19,,262.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,262.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,75.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.25,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,262.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,220.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.78,280.25,
US IMPLANT 3.5 CORT N-L SCREW 32351-26,2111373,CDM,278,RC,,,both,,,154.57,92.74,,115.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,115.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.47,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,33.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,115.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,97.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.67,123.66,
US IMPLANT 3.5 CORT SCREW 32351-14/16/1,2111102,CDM,278,RC,,,both,,,394.55,236.73,,295.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,295.91,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.46,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,84.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,295.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,248.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.84,315.64,
US IMPLANT 3.5 LOCKING CONT SCREW 37351,2111251,CDM,278,RC,,,both,,,291.64,174.98,,218.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,218.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,189.57,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,62.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,218.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,183.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.76,233.31,
US IMPLANT 3.5 LOCKING CONT SCREW 37351-,2111372,CDM,278,RC,,,both,,,583.28,349.97,,437.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,437.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,379.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,125.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,466.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,437.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,367.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.51,466.62,
US IMPLANT 4.2 CANC L SCREW 37422-36,2111207,CDM,278,RC,,,both,,,499.47,299.68,,374.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,374.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,324.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,107.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,374.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,314.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.34,399.58,
US IMPLANT 4.2 CANC L SCREW 37422-36,2111836,CDM,278,RC,,,both,,,499.47,299.68,,374.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,374.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,324.66,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,107.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,374.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,314.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.34,399.58,
US IMPLANT 4.5 CANN SCREW 50 #4516,2111257,CDM,278,RC,,,both,,,1074.48,644.69,,805.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,805.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,698.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,231.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,859.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,805.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,676.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.16,859.58,
US IMPLANT 4.5 CANN SCREW 68 #4523,2111258,CDM,278,RC,,,both,,,1074.48,644.69,,805.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,805.86,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,228.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,698.41,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,231.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,859.58,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,805.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,805.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,676.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.16,859.58,
US IMPLANT 4.5 CORT SCREW32451-24,2111203,CDM,278,RC,,,both,,,198.6,119.16,,148.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,148.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,42.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,158.88,
US IMPLANT 5 HOLE R DORSO 21241-5,2111370,CDM,278,RC,,,both,,,3129.55,1877.73,,2347.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2347.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,666.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,666.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2034.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,672.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2503.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2347.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2347.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2347.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2347.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1971.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.24,2503.64,
US IMPLANT 8 HOLE OLECR PLATE 21111-8,2111371,CDM,278,RC,,,both,,,2933.81,1760.29,,2200.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2200.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,624.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,624.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1906.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,630.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2347.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2200.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2200.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,601.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1848.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,601.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,601.14,2347.05,
US IMPLANT CLAVICLE PLATE 21121-6,2111101,CDM,278,RC,,,both,,,1803.43,1082.06,,1352.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1352.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,384.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1172.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,387.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1442.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1352.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1352.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1136.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.52,1442.74,
US IMPLANT CLAVICLE PLATE 4 HOLE 21123-4,2111248,CDM,278,RC,,,both,,,2150.98,1290.59,,1613.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1613.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,458.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1398.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,462.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1720.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1613.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1613.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1613.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1613.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1355.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,440.74,1720.78,
US IMPLANT DRILL BIT 100MM 1203-100,2111249,CDM,278,RC,,,both,,,115.54,69.32,,86.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,86.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,24.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.43,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,86.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.67,92.43,
US IMPLANT DRILL BIT 180MM 1253-110,2111250,CDM,278,RC,,,both,,,174.2,104.52,,130.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,130.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.23,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,37.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,130.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.69,139.36,
US IMPLANT DRILL BIT 2.7MMX 61273-100,2111369,CDM,278,RC,,,both,,,95.9,57.54,,71.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,71.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,20.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,71.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.65,76.72,
US IMPLANT DRILL BIT 61203-100,2111368,CDM,278,RC,,,both,,,95.9,57.54,,71.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,71.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,20.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,71.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.65,76.72,
US IMPLANT DRILL BIT 61253-180,2111103,CDM,278,RC,,,both,,,321.03,192.62,,240.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,240.77,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,208.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,69.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,256.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,240.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,202.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.78,256.82,
US IMPLANT GUIDE WIRE 35204-228,2111205,CDM,278,RC,,,both,,,78.29,46.97,,58.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,58.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,16.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.63,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,58.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.04,62.63,
US IMPLANT GUIDE WIRE 4.0 0012-15,2111255,CDM,278,RC,,,both,,,193.72,116.23,,145.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,145.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,41.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,145.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,122.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,154.98,
US IMPLANT GUIDE WIRE 6.5/7.3 1016-15,2111256,CDM,278,RC,,,both,,,193.72,116.23,,145.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,145.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.92,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,41.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,145.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,122.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,154.98,
US IMPLANT HUM HEAD PLATE 3HOLE211313,2111206,CDM,278,RC,,,both,,,186.93,112.16,,140.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,140.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.5,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,40.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,149.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,140.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,117.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.3,149.54,
US IMPLANT K WIRE 1.6X150 35164-450,2111390,CDM,278,RC,,,both,,,158.5,95.1,,118.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,118.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,34.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,126.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,99.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.48,126.8,
US IMPLANT LOCKING CORT SCREW 37351,2111119,CDM,278,RC,,,both,,,298.96,179.38,,224.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,224.22,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.32,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,64.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,239.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,224.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,188.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.26,239.17,
US IMPLANT LOCKING CORT SCREW N-37351,2111104,CDM,278,RC,,,both,,,310.95,186.57,,233.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,233.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,66.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,233.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.71,248.76,
US IMPLANT SPIRAL DRILL BIT 61353-110,2111204,CDM,278,RC,,,both,,,198.6,119.16,,148.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,148.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,42.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.88,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.69,158.88,
WRIGHT,2110730,CDM,278,RC,,,both,,,1158.5,695.1,,868.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,868.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,246.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,753.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,249.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,926.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,868.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,868.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,868.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,868.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,729.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.38,926.8,
WRIGHT,2111099,CDM,278,RC,,,both,,,1805.44,1083.26,,1354.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1354.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,384.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1173.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,388.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1444.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1137.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,1444.35,
WRIGHT 2 HOLE CLAW PLATE 4013-0120,2111260,CDM,278,RC,,,both,,,3317.43,1990.46,,2488.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2488.07,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,706.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2156.33,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,713.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2653.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2488.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2488.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2488.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2488.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,679.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2089.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,679.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,679.74,2653.94,
WRIGHT 4 HOLE CLAW PLATE 4013-0020,2111261,CDM,278,RC,,,both,,,4110.03,2466.02,,3082.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3082.52,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,875.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,875.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2671.52,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,883.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3288.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3082.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3082.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3082.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3082.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,842.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2589.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,842.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,842.15,3288.02,
WRIGHT 70 SHORT SCREW 4417-7016,2111394,CDM,278,RC,,,both,,,2006.06,1203.64,,1504.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1504.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1303.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,431.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1263.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,1604.85,
WRIGHT ACE LINER 32MM 3641-32X2,2110493,CDM,278,RC,C1713,HCPCS,both,,,2206.67,1324,,1655,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1655,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,470.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1434.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,474.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1765.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1655,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1390.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.15,1765.34,
WRIGHT ACETABULAR SHELL 3643-0052,2110492,CDM,278,RC,C1776,HCPCS,both,,,5075.45,3045.27,,3806.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3806.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1081.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1081.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3299.04,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1091.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4060.36,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3806.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3806.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3806.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3806.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1039.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3197.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1039.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1039.96,4060.36,
WRIGHT ALLOMATRIX C BONE PUTTY 860C-0500,2111126,CDM,278,RC,C1768,HCPCS,both,,,1935.93,1161.56,,1451.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1451.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,412.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,412.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1258.35,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,416.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1548.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1451.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1451.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1451.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1451.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1219.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,396.67,1548.74,
WRIGHT APICAL HOLE PLUG 3818-0002,2110494,CDM,278,RC,,,both,,,220.67,132.4,,165.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,165.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,47.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,176.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,176.54,
WRIGHT AR SCREW 8021-080,2110992,CDM,278,RC,,,both,,,571.72,343.03,,428.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,428.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,371.62,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,122.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,457.38,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,428.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,360.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.15,457.38,
WRIGHT BIOFOAM TIBIAL BASE 4+ KTSC-FM41,2111297,CDM,278,RC,C1776,HCPCS,both,,,4299.93,2579.96,,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,3439.94,
WRIGHT BIOFOAM TIBIAL BASE KTSC-FM30,2111245,CDM,278,RC,C1776,HCPCS,both,,,4299.93,2579.96,,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,3439.94,
WRIGHT BIOFOAM TIBIAL BASE S2 KTSC-FM20,2111300,CDM,278,RC,C1776,HCPCS,both,,,4299.93,2579.96,,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,3439.94,
WRIGHT BIOFOAM TIBIAL BASE S2 KTSC-FM21,2111295,CDM,278,RC,C1776,HCPCS,both,,,4299.93,2579.96,,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,3439.94,
WRIGHT BIPOLAR Z STEM PHAO-0260,2110773,CDM,278,RC,,,both,,,3410.37,2046.22,,2557.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2557.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,726.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,726.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2216.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,733.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2728.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2148.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,2728.3,
WRIGHT BLOCKING SCREW 60X5.0,2111272,CDM,278,RC,,,both,,,557.82,334.69,,418.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,418.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,118.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,362.58,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,119.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.26,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,418.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,351.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.3,446.26,
WRIGHT BOW PLATE DC2832-000,2111210,CDM,278,RC,,,both,,,2999.16,1799.5,,2249.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2249.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,638.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,638.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1949.45,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,644.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2399.33,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2249.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2249.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2249.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2249.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,614.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1889.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,614.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,614.53,2399.33,
WRIGHT BUTTRESS SCREW 26 5941-2526,2111386,CDM,278,RC,,,both,,,429.56,257.74,,322.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,322.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,279.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,92.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,322.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,270.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.02,343.65,
WRIGHT BUTTRESS SCREW 5941-2524,2109877,CDM,278,RC,,,both,,,429.56,257.74,,322.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,322.17,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,279.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,92.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,343.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,322.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,322.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,270.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.02,343.65,
WRIGHT CALIBRATED DRILL 0217,2111098,CDM,278,RC,,,both,,,1571.41,942.85,,1178.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1178.56,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,334.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,334.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1021.42,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,337.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1257.13,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1178.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1178.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,989.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,321.98,1257.13,
WRIGHT CALIBRATED DRILL 4.0 SHORT 0210,2111274,CDM,278,RC,,,both,,,459.91,275.95,,344.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,344.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,298.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,98.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.93,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,289.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.24,367.93,
WRIGHT CANC SCREW 6.5X15 7552-0015,2111376,CDM,278,RC,,,both,,,524.51,314.71,,393.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,393.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,419.61,
WRIGHT CANC SCREW 6.5X20 7552-0020,2111377,CDM,278,RC,,,both,,,524.51,314.71,,393.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,393.38,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,112.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.61,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,393.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,330.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.47,419.61,
WRIGHT CANCELLOUS SCREW 1808-0302,2110496,CDM,278,RC,,,both,,,264.8,158.88,,198.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,198.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,172.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,56.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,211.84,
WRIGHT CANCELLOUS SCREW 6.5 1808-0303,2111360,CDM,278,RC,,,both,,,264.8,158.88,,198.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,198.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,172.12,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,56.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,166.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.26,211.84,
WRIGHT CANCELLOUS SCREW 8022-035,2111095,CDM,278,RC,,,both,,,1136.76,682.06,,852.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,852.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,242.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,242.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,738.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,244.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,909.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,852.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,852.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,852.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,852.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,716.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.92,909.41,
WRIGHT CANN SCREW 4.3 4411.0030,2110786,CDM,278,RC,,,both,,,692.13,415.28,,519.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,519.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,147.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,147.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,449.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,148.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,553.7,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,519.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,519.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,436.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.82,553.7,
WRIGHT CANNULATED SCREW 4417-4516,2110791,CDM,278,RC,,,both,,,2195.64,1317.38,,1646.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1646.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,467.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,467.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1427.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,472.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1756.51,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1646.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1646.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1646.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1646.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1383.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.89,1756.51,
WRIGHT CEMENT 1410-3000,2110633,CDM,278,RC,,,both,,,315.62,189.37,,236.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,236.72,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.15,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,67.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.5,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,236.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,198.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.67,252.5,
WRIGHT CEMENT BOWLS 1400-2100,2110634,CDM,278,RC,,,both,,,419.27,251.56,,314.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,314.45,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,272.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,90.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.42,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,264.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.91,335.42,
WRIGHT COMP SCREW 44177516,2110785,CDM,278,RC,,,both,,,2195.64,1317.38,,1646.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1646.73,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,467.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,467.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1427.17,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,472.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1756.51,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1646.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1646.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1646.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1646.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1383.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.89,1756.51,
WRIGHT CORT LAG SCREW 5.0 1045-095,2110993,CDM,278,RC,,,both,,,872.7,523.62,,654.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,654.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,185.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,185.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,567.26,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,187.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,654.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,654.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,549.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.82,698.16,
WRIGHT CORTIAL SCREW 8001-060,2111273,CDM,278,RC,,,both,,,387.55,232.53,,290.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,290.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,251.91,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,83.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,290.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,244.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.41,310.04,
WRIGHT CORTICAL SCREW 5941-2716,2109876,CDM,278,RC,,,both,,,164.76,98.86,,123.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,123.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,123.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,103.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,131.81,
WRIGHT CORTICAL SCREW 8010-250,2111096,CDM,278,RC,,,both,,,936.14,561.68,,702.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,702.11,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,199.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,608.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,748.91,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,702.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,702.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,589.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.82,748.91,
WRIGHT CORTICAL SCREW GOLD 12 5941-2712,2111387,CDM,278,RC,,,both,,,164.76,98.86,,123.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,123.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.09,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,131.81,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,123.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,103.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.76,131.81,
WRIGHT COSERVE HEAD 38AM-4200,2110864,CDM,278,RC,C1776,HCPCS,both,,,6178.78,3707.27,,4634.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4634.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1316.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1316.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4016.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1328.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4943.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4634.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4634.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4634.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4634.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1266.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3892.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1266.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1266.03,4943.02,
WRIGHT DARCO SCREW SCN655062,2111436,CDM,278,RC,,,both,,,939.43,563.66,,704.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,704.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,610.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,751.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,591.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,751.54,
WRIGHT DARCO SCREW SCN655562,2111437,CDM,278,RC,,,both,,,939.43,563.66,,704.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,704.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,610.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,751.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,591.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,751.54,
WRIGHT DARCO WASHER S0913002,2111438,CDM,278,RC,,,both,,,228.31,136.99,,171.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,171.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,49.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,171.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.78,182.65,
WRIGHT DISTAL RADIUS IMPLANT 5941-0003,2109875,CDM,278,RC,,,both,,,5185.78,3111.47,,3889.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3889.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1104.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3370.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1114.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4148.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3889.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1062.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3267.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1062.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1062.57,4148.62,
WRIGHT DOUBLE HIGH TIBAL I 4R KIDH-414R,2111296,CDM,278,RC,C1776,HCPCS,both,,,3073.96,1844.38,,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1998.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2459.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1936.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,2459.17,
WRIGHT DRILL BIT 2.5 4014-2500,2111262,CDM,278,RC,,,both,,,293.55,176.13,,220.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,220.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,190.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,63.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,184.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,234.84,
WRIGHT DRILL BIT 2.5MM MRS SYSTEM DC5136,2111016,CDM,278,RC,,,both,,,293.55,176.13,,220.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,220.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,190.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,63.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,184.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,234.84,
WRIGHT DRILL BIT 3.0 4411-2003,2111311,CDM,278,RC,,,both,,,293.55,176.13,,220.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,220.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,190.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,63.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,234.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,184.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.15,234.84,
WRIGHT DRILL BIT DC5106,2111212,CDM,278,RC,,,both,,,280.82,168.49,,210.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,210.62,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,182.53,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,60.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,224.66,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,176.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.54,224.66,
WRIGHT DRIVE SHAFT CANNULA 2007-ST20,2111041,CDM,278,RC,,,both,,,341.08,204.65,,255.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,255.81,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,221.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,73.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,255.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,214.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.89,272.86,
WRIGHT DYNASTY COCR LINER DLCO-GF42,2110865,CDM,278,RC,C1776,HCPCS,both,,,2607.91,1564.75,,1955.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1955.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,555.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1695.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,560.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2086.33,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1642.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,2086.33,
WRIGHT DYNASTY PC SHELL DSPC-GF56,2110862,CDM,278,RC,C1776,HCPCS,both,,,3009.13,1805.48,,2256.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2256.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,640.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1955.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,646.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2407.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1895.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,2407.3,
WRIGHT FEMORAL AUGMENT KFDA-N310,2111071,CDM,278,RC,,,both,,,2140.05,1284.03,,1605.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1605.04,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,455.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,455.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1391.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,460.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1712.04,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1605.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1605.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1605.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1605.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1348.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,438.5,1712.04,
WRIGHT FEMORAL HEAD 2600-0017,2111325,CDM,278,RC,C1776,HCPCS,both,,,1805.44,1083.26,,1354.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1354.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,384.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1173.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,388.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1444.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1137.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,1444.35,
WRIGHT FEMORAL HEAD 2600-0019,2110728,CDM,278,RC,C1776,HCPCS,both,,,1805.44,1083.26,,1354.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1354.08,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,384.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1173.54,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,388.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1444.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1354.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1137.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.93,1444.35,
WRIGHT FEMORAL HEAD 2600-0021,2110495,CDM,278,RC,,,both,,,1986,1191.6,,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1290.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,426.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1588.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1251.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,1588.8,
WRIGHT FEMORAL HEAD 2600-0023,2111419,CDM,278,RC,,,both,,,1986,1191.6,,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1290.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,426.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1588.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1251.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,1588.8,
WRIGHT FEMORAL HEAD 36MM 2600-0026/027,2111347,CDM,278,RC,,,both,,,5362.21,3217.33,,4021.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4021.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1142.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1142.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3485.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1152.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4289.77,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4021.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4021.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4021.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4021.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1098.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3378.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1098.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1098.72,4289.77,
WRIGHT FEMORAL NON POROUS 2L KFTC-NP2L,2111430,CDM,278,RC,C1776,HCPCS,both,,,3749.96,2249.98,,2812.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2812.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,798.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,798.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2437.47,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,806.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2999.97,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2812.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2812.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2812.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2812.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2362.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.37,2999.97,
WRIGHT FEMORAL NON POROUS 2R KFTC-NP2R,2111303,CDM,278,RC,C1776,HCPCS,both,,,4228.01,2536.81,,3171.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3171.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,900.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2748.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,909.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3382.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3171.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3171.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3171.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3171.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2663.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.32,3382.41,
WRIGHT FEMORAL NON POROUS R 4 KFTC-NP4R,2110501,CDM,278,RC,C1776,HCPCS,both,,,4228.01,2536.81,,3171.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3171.01,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,900.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,900.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2748.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,909.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3382.41,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3171.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3171.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3171.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3171.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2663.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,866.32,3382.41,
WRIGHT FEMORAL POROUS 2L KFTC-PC2L,2111299,CDM,278,RC,C1776,HCPCS,both,,,4701.06,2820.64,,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3760.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,3760.85,
WRIGHT FEMORAL POROUS 2R KFTC-NC2R,2111362,CDM,278,RC,C1776,HCPCS,both,,,4701.06,2820.64,,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3760.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,3760.85,
WRIGHT FEMORAL POROUS 3L KFTC-PC3L,2111382,CDM,278,RC,C1776,HCPCS,both,,,4701.06,2820.64,,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3760.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,3760.85,
WRIGHT FEMORAL POROUS R 4 KFTC-PC4R,2111298,CDM,278,RC,C1776,HCPCS,both,,,4701.06,2820.64,,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3760.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,3760.85,
WRIGHT GLADIATOR BIPOLAR GLBP-3246,2111418,CDM,278,RC,,,both,,,2328.99,1397.39,,1746.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1746.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1513.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,500.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1863.19,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1467.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,1863.19,
WRIGHT GLADIATOR BIPOLAR GLBP-3650,2110881,CDM,278,RC,,,both,,,2328.99,1397.39,,1746.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1746.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1513.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,500.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1863.19,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1467.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,1863.19,
WRIGHT GLADIATOR BIPOLAR GLBP-3653,2111434,CDM,278,RC,,,both,,,2328.99,1397.39,,1746.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1746.74,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,496.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1513.84,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,500.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1863.19,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1746.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1467.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,477.21,1863.19,
WRIGHT GLADIATOR BIPOLAR GLBP2842,2110983,CDM,278,RC,,,both,,,2387.24,1432.34,,1790.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1790.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,508.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1551.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,513.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1909.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1790.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1790.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1790.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1790.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,489.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1503.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,489.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,489.15,1909.79,
WRIGHT GLADIATOR BIPOLAR GLBP2844,2111324,CDM,278,RC,,,both,,,2387.24,1432.34,,1790.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1790.43,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,508.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1551.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,513.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1909.79,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1790.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1790.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1790.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1790.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,489.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1503.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,489.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,489.15,1909.79,
WRIGHT IGNITE MINI POWER MIX876P-0400,2111288,CDM,278,RC,,,both,,,2325.07,1395.04,,1743.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1743.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,495.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1511.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,499.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1860.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1743.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1743.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,476.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1464.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,476.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,476.41,1860.06,
WRIGHT IGNITE POWER MIX 876P-200,2111269,CDM,278,RC,,,both,,,5861.69,3517.01,,4396.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4396.27,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1248.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1248.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3810.1,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1260.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4689.35,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4396.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4396.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4396.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4396.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1201.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3692.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1201.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1201.06,4689.35,
WRIGHT INSERT GREEN 1004,2111266,CDM,278,RC,,,both,,,778.92,467.35,,584.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,584.19,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,506.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,167.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,623.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,584.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,490.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.6,623.14,
WRIGHT INSERT KIRV-225S,2111107,CDM,278,RC,,,both,,,2607.91,1564.75,,1955.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1955.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,555.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1695.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,560.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2086.33,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1642.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,2086.33,
WRIGHT K WIRE 2.5X230CM 4418-2523,2111307,CDM,278,RC,,,both,,,163.06,97.84,,122.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,122.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,130.45,
WRIGHT K WIRE 2.5X230CM 4418-2525,2111395,CDM,278,RC,,,both,,,163.06,97.84,,122.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,122.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,130.45,
WRIGHT K WIRE 228MM 5601-0228,2111320,CDM,278,RC,,,both,,,163.06,97.84,,122.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,122.3,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,35.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.41,130.45,
WRIGHT K WIRE 3.0 NK013027,2111439,CDM,278,RC,,,both,,,228.31,136.99,,171.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,171.23,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.4,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,49.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.65,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,171.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.78,182.65,
WRIGHT K WIRE1.6 X150 4411-2008,2110783,CDM,278,RC,,,both,,,147.15,88.29,,110.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,110.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.65,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,31.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.72,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,92.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.15,117.72,
WRIGHT LINEAGE SHELL 3658-0064,2110959,CDM,278,RC,,,both,,,6620.12,3972.07,,4965.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4965.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1410.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1410.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4303.08,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1423.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5296.1,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4965.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4965.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4965.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4965.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4170.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1356.46,5296.1,
WRIGHT LOCKED SCREW DC2825-012,2111211,CDM,278,RC,,,both,,,351.05,210.63,,263.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,263.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.18,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,75.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,280.84,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,263.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,221.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,280.84,
WRIGHT MICRO MIIG HV GRAFT 84XSO404,2109947,CDM,278,RC,,,both,,,2272.87,1363.72,,1704.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1704.65,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,484.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1477.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,488.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1818.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1704.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1704.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1704.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1704.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1431.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,465.71,1818.3,
WRIGHT MICRONAIL S 2 5941-0002,2111385,CDM,278,RC,,,both,,,5185.78,3111.47,,3889.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3889.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1104.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1104.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3370.76,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1114.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4148.62,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3889.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3889.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1062.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3267.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1062.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1062.57,4148.62,
WRIGHT MODULAR NAIL 1012-200,2111282,CDM,278,RC,,,both,,,3621.07,2172.64,,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2353.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,778.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2896.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2281.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,2896.86,
WRIGHT MODULAR RADIAL HEAD 496-H422,2111283,CDM,278,RC,,,both,,,3513.06,2107.84,,2634.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2634.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,748.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,748.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2283.49,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,755.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2810.45,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2634.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2634.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2634.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2634.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,719.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2213.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,719.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,719.83,2810.45,
WRIGHT MODULAR RADIAL HEAD STEM 496-H422,2111284,CDM,278,RC,,,both,,,4178.57,2507.14,,3133.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3133.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,890.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,890.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2716.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,898.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3342.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3133.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3133.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3133.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3133.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2632.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.19,3342.86,
WRIGHT MUC SCREW 4.3X40 4411-0027,2111310,CDM,278,RC,,,both,,,704.54,422.72,,528.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,528.41,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,151.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,563.63,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,528.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,443.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.36,563.63,
WRIGHT MUC SCREW 7.0 X50CM 4417-5016,2111309,CDM,278,RC,,,both,,,2006.06,1203.64,,1504.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1504.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1303.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,431.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1263.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,1604.85,
WRIGHT MUC SCREW 7.0 X60CM 4417-6016,2111308,CDM,278,RC,,,both,,,2006.06,1203.64,,1504.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1504.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1303.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,431.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1263.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,1604.85,
WRIGHT NAIL 1038-200,2111117,CDM,278,RC,,,both,,,3621.07,2172.64,,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2353.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,778.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2896.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2281.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,2896.86,
WRIGHT NAIL 10MMX15CM 1010-150,2111265,CDM,278,RC,,,both,,,3728.42,2237.05,,2796.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2796.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,794.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,794.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2423.47,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,801.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2982.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2796.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2796.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2796.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2796.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,763.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2348.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,763.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,763.95,2982.74,
WRIGHT OLIVE K WIRE DC9212,2111263,CDM,278,RC,,,both,,,185.98,111.59,,139.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,139.49,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.89,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,39.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,139.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,117.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.11,148.78,
WRIGHT OSTEOSET 25CC BEAD KIT 8400-311,2111341,CDM,278,RC,,,both,,,1831.96,1099.18,,1373.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1373.97,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,390.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,390.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1190.77,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,393.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1465.57,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1373.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1373.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1373.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1373.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1154.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,375.37,1465.57,
WRIGHT OSTEOSET PELLETS 8400-0511,2109650,CDM,278,RC,,,both,,,1133.46,680.08,,850.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,850.1,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,241.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,736.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,243.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,906.77,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,850.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,714.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,232.25,906.77,
WRIGHT PATELLA 35MM KPON-TP35,2110503,CDM,278,RC,C1776,HCPCS,both,,,2302.79,1381.67,,1727.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1727.09,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,490.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,490.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1496.81,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,495.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1842.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1727.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1727.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1727.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1727.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,471.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1450.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,471.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,471.84,1842.23,
WRIGHT PC SHELL DSPC-GC50,2111040,CDM,278,RC,,,both,,,3009.13,1805.48,,2256.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2256.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,640.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1955.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,646.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2407.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1895.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,2407.3,
WRIGHT PC SHELL60MM G DSPC-GG60,2111359,CDM,278,RC,,,both,,,3009.13,1805.48,,2256.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2256.85,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,640.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,640.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1955.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,646.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2407.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2256.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1895.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,616.57,2407.3,
WRIGHT PIN PACK K000-1298,2110935,CDM,278,RC,,,both,,,1158.5,695.1,,868.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,868.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,246.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,753.03,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,249.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,926.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,868.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,868.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,868.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,868.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,729.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,237.38,926.8,
WRIGHT PINDRBLT (A),2110782,CDM,278,RC,,,both,,,882.67,529.6,,662,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,662,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,188.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,573.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,189.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,662,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,556.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.86,706.14,
WRIGHT PLATE OMM DC2801-000,2111289,CDM,278,RC,C1713,HCPCS,both,,,3072.79,1843.67,,2304.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2304.59,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1997.31,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2458.23,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2304.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2304.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1935.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.61,2458.23,
WRIGHT POLY LINER DLXP-LG42,2111092,CDM,278,RC,,,both,,,1348.08,808.85,,1011.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1011.06,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,287.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,876.25,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,289.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1078.46,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1011.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1011.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1011.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1011.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,849.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.22,1078.46,
WRIGHT PRESSFIT KEEL PRIM KSPP-1512,2111302,CDM,278,RC,C1776,HCPCS,both,,,2497.36,1498.42,,1873.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1873.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,531.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,531.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1623.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,536.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1997.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1873.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1873.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1873.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1873.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1573.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.71,1997.89,
WRIGHT PRESSFIT KEEL PRIM KSPP-1534,2111246,CDM,278,RC,C1776,HCPCS,both,,,2497.36,1498.42,,1873.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1873.02,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,531.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,531.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1623.28,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,536.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1997.89,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1873.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1873.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1873.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1873.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1573.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,511.71,1997.89,
WRIGHT PRIM FEMORAL POROUSKFTC-PC3R,2111247,CDM,278,RC,C1776,HCPCS,both,,,4701.06,2820.64,,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1001.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3055.69,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1010.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3760.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3525.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2961.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,963.25,3760.85,
WRIGHT PRO-DENSE BONE GRAFT 87SR-0404,2111024,CDM,278,RC,,,both,,,3791.55,2274.93,,2843.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2843.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,807.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,807.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2464.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,815.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3033.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2843.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2843.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2843.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2843.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,776.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2388.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,776.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,776.89,3033.24,
WRIGHT PROFEMUR PHA0-1204,2110497,CDM,278,RC,C1776,HCPCS,both,,,2206.67,1324,,1655,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1655,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,470.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1434.34,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,474.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1765.34,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1655,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1655,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1390.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.15,1765.34,
WRIGHT PROFEMUR PHAO-0266,2110729,CDM,278,RC,C1776,HCPCS,both,,,9047.46,5428.48,,6785.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,6785.6,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1927.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1927.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5880.85,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1945.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7237.97,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,6785.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6785.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6785.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6785.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5699.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1853.82,7237.97,
WRIGHT PROFEMUR PHAO-0268,2111346,CDM,278,RC,C1776,HCPCS,both,,,3327.2,1996.32,,2495.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2495.4,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,708.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,708.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2162.68,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,715.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2661.76,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2495.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2495.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2495.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2495.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,681.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2096.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,681.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,681.74,2661.76,
WRIGHT PROFEMUR SHORT PHAO-1202,2110465,CDM,278,RC,C1776,HCPCS,both,,,1986,1191.6,,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1290.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,426.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1588.8,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1489.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1251.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,406.93,1588.8,
WRIGHT PROFEMUR STEM 6 PHA0-0270,2111361,CDM,278,RC,C1776,HCPCS,both,,,3228.42,1937.05,,2421.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2421.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,687.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,687.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2098.47,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,694.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2582.74,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2421.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2421.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2421.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2421.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,661.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2033.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,661.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,661.5,2582.74,
WRIGHT REVISION CCK INSERT KIRV-314S,2111074,CDM,278,RC,,,both,,,3698.83,2219.3,,2774.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2774.12,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,787.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,787.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2404.24,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,795.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2959.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2774.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2774.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2774.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2774.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,757.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2330.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,757.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,757.89,2959.06,
WRIGHT REVISION FEMORAL W/PLUG KFCC-NP3R,2111072,CDM,278,RC,,,both,,,8626.18,5175.71,,6469.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,6469.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1837.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1837.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5607.02,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1854.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6900.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,6469.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6469.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6469.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6469.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1767.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5434.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1767.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1767.5,6900.94,
WRIGHT SCREW 3.5 DC2820-014,2111290,CDM,278,RC,C1713,HCPCS,both,,,381.71,229.03,,286.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,286.28,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.11,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,82.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.37,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.21,305.37,
WRIGHT SCREWS 4013-3518,2111259,CDM,278,RC,,,both,,,508.81,305.29,,381.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,381.61,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,330.73,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,109.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,407.05,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,381.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,320.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.26,407.05,
WRIGHT SHORT 6.5X35 SCREW SCN65-3562,2111213,CDM,278,RC,,,both,,,939.43,563.66,,704.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,704.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,610.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,751.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,591.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,751.54,
WRIGHT SHORT SCEEW 6.5 X40 SCN65-4062,2111319,CDM,278,RC,,,both,,,939.43,563.66,,704.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,704.57,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,610.63,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,201.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,751.54,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,704.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,591.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.49,751.54,
WRIGHT STEM EXTENSION KSP1-4100,2111068,CDM,278,RC,,,both,,,2173.78,1304.27,,1630.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1630.34,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,463.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,463.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1412.96,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,467.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1739.02,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1630.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1630.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1630.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1630.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1369.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,445.41,1739.02,
WRIGHT STEM EXTENSION KSP1-5100,2111108,CDM,278,RC,,,both,,,2006.06,1203.64,,1504.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1504.55,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1303.94,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,431.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1604.85,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1263.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.04,1604.85,
WRIGHT TIB BASE BIOFOA S 3 KTSL-FM30,2111381,CDM,278,RC,C1776,HCPCS,both,,,4299.93,2579.96,,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,3439.94,
WRIGHT TIB BASE BIOFOAM 2+KTSL-FM21,2111363,CDM,278,RC,C1776,HCPCS,both,,,4299.93,2579.96,,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,3439.94,
WRIGHT TIBIAL BASE 3 KTTI-NP31,2111075,CDM,278,RC,,,both,,,4592,2755.2,,3444,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3444,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,978.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,978.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2984.8,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,987.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3673.6,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3444,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3444,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3444,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3444,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,940.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2892.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,940.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,940.9,3673.6,
WRIGHT TIBIAL BASE BIOFOAM KTSL-FM30,2111358,CDM,278,RC,C1776,HCPCS,both,,,4299.93,2579.96,,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,3439.94,
WRIGHT TIBIAL BASE BIOFOAM KTSS-FM31,2111286,CDM,278,RC,C1776,HCPCS,both,,,4299.93,2579.96,,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,915.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2794.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,924.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3439.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3224.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2708.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,881.06,3439.94,
WRIGHT TIBIAL BASE KTCC-NP41,2110500,CDM,278,RC,C1776,HCPCS,both,,,3449.09,2069.45,,2586.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2586.82,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,734.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,734.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2241.91,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,741.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2759.27,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2586.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2586.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2586.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2586.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2172.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,706.72,2759.27,
WRIGHT TIBIAL BASE KTTI-NP20,2111429,CDM,278,RC,,,both,,,3610.98,2166.59,,2708.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2708.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,769.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,769.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2347.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,776.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2888.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2708.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2708.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2708.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2708.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,739.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2274.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,739.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,739.89,2888.78,
WRIGHT TIBIAL BASE KTTI-NP21,2111109,CDM,278,RC,,,both,,,3610.98,2166.59,,2708.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2708.24,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,769.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,769.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2347.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,776.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2888.78,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2708.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2708.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2708.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2708.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,739.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2274.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,739.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,739.89,2888.78,
WRIGHT TIBIAL BLOCK AUGMENT KTAG-B315,2111067,CDM,278,RC,,,both,,,2427.34,1456.4,,1820.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1820.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,517.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,517.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1577.77,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,521.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1941.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1820.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1820.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1529.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,497.36,1941.87,
WRIGHT TIBIAL BLOCK AUGMENT KTAG-B415,2111069,CDM,278,RC,,,both,,,2039.05,1223.43,,1529.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1529.29,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,434.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,434.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1325.38,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,438.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1631.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1529.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1529.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1529.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1529.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1284.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,417.8,1631.24,
WRIGHT TIBIAL INSERT 2L KIDH-212L,2111301,CDM,278,RC,C1776,HCPCS,both,,,3073.96,1844.38,,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1998.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2459.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1936.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,2459.17,
WRIGHT TIBIAL INSERT 2L KIDH-217L,2111428,CDM,278,RC,C1776,HCPCS,both,,,3073.96,1844.38,,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1998.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2459.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1936.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,2459.17,
WRIGHT TIBIAL INSERT 2L KIMP-214L,2111435,CDM,278,RC,C1776,HCPCS,both,,,4671.99,2803.19,,3503.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3503.99,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,995.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,995.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3036.79,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1004.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3737.59,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3503.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3503.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3503.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3503.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,957.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2943.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,957.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,957.29,3737.59,
WRIGHT TIBIAL INSERT 2R KIDH-212R,2111294,CDM,278,RC,C1776,HCPCS,both,,,3073.96,1844.38,,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1998.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2459.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1936.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,2459.17,
WRIGHT TIBIAL INSERT 3L KIDH-213L,2111383,CDM,278,RC,C1776,HCPCS,both,,,3073.96,1844.38,,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1998.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2459.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1936.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,2459.17,
WRIGHT TIBIAL INSERT 3R KIDH-310R,2111357,CDM,278,RC,C1776,HCPCS,both,,,3073.96,1844.38,,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1998.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2459.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1936.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,2459.17,
WRIGHT TIBIAL INSERT KIDH-412R,2110502,CDM,278,RC,C1776,HCPCS,both,,,3073.96,1844.38,,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,654.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1998.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,660.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2459.17,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2305.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1936.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.85,2459.17,
WRIGHT TIBIAL NAIL 1111-330,2111271,CDM,278,RC,,,both,,,3239.14,1943.48,,2429.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2429.36,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,689.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2105.44,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,696.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2591.31,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2429.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2429.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2429.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2429.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2040.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.7,2591.31,
WRIGHT TOTAL HIP PHAO-0260,2110499,CDM,278,RC,C1776,HCPCS,both,,,3410.37,2046.22,,2557.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2557.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,726.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,726.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2216.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,733.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2728.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2148.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,2728.3,
WRIGHT TOTAL HIP STEM 3 PHAO-0264,2111433,CDM,278,RC,C1776,HCPCS,both,,,3410.37,2046.22,,2557.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2557.78,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,726.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,726.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2216.74,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,733.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2728.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2557.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2148.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,698.78,2728.3,
WRIGHT TOTAL SHO HEAD 44MM 870-H248,2111366,CDM,278,RC,C1776,HCPCS,both,,,2383.52,1430.11,,1787.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1787.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,507.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,507.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1549.29,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,512.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1906.82,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1787.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1787.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1501.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.38,1906.82,
WRIGHT TOTAL SHO STEM 14X125 870-SS14,2111367,CDM,278,RC,C1776,HCPCS,both,,,4719.84,2831.9,,3539.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,3539.88,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1005.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1005.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3067.9,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1014.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3775.87,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,3539.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3539.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3539.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3539.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,967.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2973.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,967.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,967.1,3775.87,
WRIGHT TOTAL SHOULDER HEAD 870-H248,2110866,CDM,278,RC,C1776,HCPCS,both,,,3894.88,2336.93,,2921.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2921.16,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,829.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,829.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2531.67,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,837.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3115.9,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2921.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2921.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2921.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2921.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,798.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2453.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,798.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,798.06,3115.9,
WRIGHT TOTAL SHOULDER STEM 870-SS12,2110867,CDM,278,RC,C1776,HCPCS,both,,,7712.42,4627.45,,5784.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,5784.32,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1642.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1642.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5013.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1658.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6169.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,5784.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5784.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5784.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5784.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1580.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4858.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1580.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1580.27,6169.94,
WRIGHT TRACH NAIL 135X13 1039-200,2110994,CDM,278,RC,,,both,,,3621.07,2172.64,,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,771.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2353.7,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,778.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2896.86,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2715.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2281.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.96,2896.86,
WRIGHT TRANS LINER 7040-3664,2110958,CDM,278,RC,,,both,,,2607.91,1564.75,,1955.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1955.93,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,555.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,555.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1695.14,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,560.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2086.33,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1955.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1642.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.36,2086.33,
WRIGHT TROCAR TIP GUIDE WIRE 0102,2111097,CDM,278,RC,,,both,,,769.05,461.43,,576.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,576.79,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,499.88,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,165.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,615.24,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,576.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,576.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,484.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.58,615.24,
WRIGHT UNI COMP FEMORAL KFNP-UN2L,2111037,CDM,278,RC,,,both,,,6539.92,3923.95,,4904.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,4904.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1393,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1393,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4250.95,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,1406.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5231.94,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,4904.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4904.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4904.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4904.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1340.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4120.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1340.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1340.03,5231.94,
WRIGHT UNI COMP TIBIAL BASE KTAP-UN28,2111036,CDM,278,RC,,,both,,,3359.55,2015.73,,2519.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2519.66,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,715.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,715.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2183.71,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,722.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2687.64,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2519.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2519.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2519.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2519.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2116.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.37,2687.64,
WRIGHT Z FEMORAL STEM PHAO-0266,2110928,CDM,278,RC,,,both,,,3751.34,2250.8,,2813.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2813.51,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,799.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2438.37,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,806.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3001.07,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2813.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2813.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2813.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2813.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2363.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,768.65,3001.07,
ZIMMER 2.5 LONG DRILL BIT 4807-108-25,2111045,CDM,278,RC,C1713,HCPCS,both,,,227.67,136.6,,170.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,170.75,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,147.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,48.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,170.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.65,182.14,
ZIMMER 9 HOLE STR PELVIC PLATE 1179-0509,2111044,CDM,278,RC,C1713,HCPCS,both,,,549.12,329.47,,411.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,411.84,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,356.93,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,118.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,439.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,411.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,345.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.51,439.3,
ZIMMER BONE PUTTY 1CC 00110501001,2111486,CDM,278,RC,,,both,,,533.95,320.37,,400.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,400.46,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,347.07,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,114.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,427.16,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,400.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,336.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.41,427.16,
ZIMMER BONE PUTTY 5CC 00110505001,2111485,CDM,278,RC,,,both,,,1618.93,971.36,,1214.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1214.2,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,344.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,344.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1052.3,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,348.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1295.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1214.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1214.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1214.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1214.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1019.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,331.72,1295.14,
ZIMMER CORTICAL SCREW 4835-26-01,2111043,CDM,278,RC,C1713,HCPCS,both,,,101.74,61.04,,76.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,76.31,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.13,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,21.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.39,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.85,81.39,
ZIMMER D.C. SKIN GRAFT 00219501300/1200,2110584,CDM,278,RC,C1713,HCPCS,both,,,135.37,81.22,,101.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,101.53,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,29.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.3,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.74,108.3,
ZIMMER K WIRE .045,2108690,CDM,278,RC,C1713,HCPCS,both,,,153.83,92.3,,115.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,115.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,33.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,115.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.52,123.06,
ZIMMER K WIRE .62,2108554,CDM,278,RC,C1713,HCPCS,both,,,66.94,40.16,,50.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,50.21,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.51,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,14.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.55,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.72,53.55,
ZIMMER K WIRE 47-262-13,2108685,CDM,278,RC,C1713,HCPCS,both,,,153.83,92.3,,115.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,115.37,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.99,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,33.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.06,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,115.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.52,123.06,
ZIMMER KNEE CONST CONDYLAR 5994-32-10,2111817,CDM,278,RC,C1776,HCPCS,both,,,3479.97,2087.98,,2609.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2609.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,741.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2261.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,748.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2783.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2609.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2609.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2609.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2609.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,713.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2192.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,713.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,713.05,2783.98,
ZIMMER KNEE TIBIAL INSERT,2111567,CDM,278,RC,C1776,HCPCS,both,,,3479.97,2087.98,,2609.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,2609.98,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,741.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,741.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2261.98,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,748.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2783.98,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,2609.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2609.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2609.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2609.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,713.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2192.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,713.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,713.05,2783.98,
ZIMMER POLY PATELLA 6301-07-103,2111568,CDM,278,RC,C1776,HCPCS,both,,,2163.92,1298.35,,1622.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,1622.94,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,460.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,460.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1406.55,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,465.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1731.14,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,1622.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1622.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1363.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.39,1731.14,
ZIMMER SCREW,2108683,CDM,278,RC,C1713,HCPCS,both,,,564.94,338.96,,423.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,423.71,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,367.21,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,121.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,451.95,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,355.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,451.95,
ZIMMER STEINMANN PIN 3/16,2102471,CDM,278,RC,C1713,HCPCS,both,,,108.85,65.31,,81.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,81.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,23.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.08,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,68.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.3,87.08,
ZIMMER STEINMANN PIN 5/32,2102472,CDM,278,RC,C1713,HCPCS,both,,,108.85,65.31,,81.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,81.64,75,,,percent of total billed charges,75% of total billed charges for implant carveouts,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.75,65,,,percent of total billed charges,65% of total billed charges for implant carveouts,23.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.08,80,,,percent of total billed charges,80% of total billed charges for implant carveouts,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,68.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.3,87.08,
Acute hepatitis panel,1502327,CDM,300,RC,80074,HCPCS,outpatient,,,170.47,102.28,,127.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,72.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,72.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,127.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,48.58,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,153.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,72.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,72.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,47.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.58,153.42,
. ANAEROBIC SENSI 1,1502376,CDM,300,RC,87181,HCPCS,outpatient,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,15.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.85,15.25,
. ANAEROBIC SENSI 2,1502377,CDM,300,RC,87181,HCPCS,outpatient,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,15.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.85,15.25,
. ANAEROBIC SENSI 3,1502378,CDM,300,RC,87181,HCPCS,outpatient,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,15.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.85,15.25,
. ANAEROBIC SENSI 4,1502379,CDM,300,RC,87181,HCPCS,outpatient,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,15.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.85,15.25,
Blood test indicating infection with Hepatitis A,1502329,CDM,300,RC,86708,HCPCS,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.04,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.04,39.58,
Blood test indicating infection with Hepatitis B,1502330,CDM,300,RC,86704,HCPCS,outpatient,,,42.89,25.73,,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,38.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,38.6,
. IA INFECTIOUS AGT ABS NOS,1502328,CDM,300,RC,86317,HCPCS,outpatient,,,53.27,31.96,,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,47.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.14,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.14,47.94,
". IMMUNOASSAY NIA AB/AG, QUANT",1502438,CDM,300,RC,8352090,HCPCS,outpatient,,,40.31,24.19,,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,36.28,
. TOXOPLASMA ANTIBODY IGG,1502366,CDM,300,RC,86777,HCPCS,outpatient,,,50.54,30.32,,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,45.49,
. TOXOPLASMA ANTIBODY IGM,1502367,CDM,300,RC,86778,HCPCS,outpatient,,,50.54,30.32,,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.67,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.67,45.49,
Test to determine levels of immunoglobulins in the blood,1502317,CDM,300,RC,82784,HCPCS,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,23.12,
Test to determine levels of immunoglobulins in the blood,1502318,CDM,300,RC,82784,HCPCS,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,23.12,
Test to determine levels of immunoglobulins in the blood,1502316,CDM,300,RC,82784,HCPCS,outpatient,,,25.69,15.41,,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,23.12,
.. SMEAR FLUORO/ACIDFAST,1502313,CDM,300,RC,87206,HCPCS,outpatient,,,49.99,29.99,,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.37,44.99,
.. SPECIMEN CONCENTRATION,1502312,CDM,300,RC,87015,HCPCS,outpatient,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,24.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.41,24.1,
.. TOTAL KAPPA LIGHT CHAINS,1502319,CDM,300,RC,83883,HCPCS,outpatient,,,54.36,32.62,,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,48.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.02,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.02,48.92,
.. TOTAL LAMDA LIGHT CHAINS,1502320,CDM,300,RC,83883,HCPCS,outpatient,,,54.36,32.62,,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,48.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.02,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.02,48.92,
"...CHLORIDE, OTHER SOURCE",1502354,CDM,300,RC,82438,HCPCS,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.05,8.12,
"...POTASSIUM, OTHER SOURCE",1502353,CDM,300,RC,84311,HCPCS,outpatient,,,12.3,7.38,,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,11.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.56,11.07,
"...SODIUM, OTHER SOURCE",1502352,CDM,300,RC,84302,HCPCS,outpatient,,,9.02,5.41,,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,8.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.93,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.93,8.12,
..ADAPTIN,1501516,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
"..ANA, IFA",1502280,CDM,300,RC,86038,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.79,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.79,26.8,
..BMP H.INFLUENZA TYPE B AG,1502345,CDM,300,RC,86403,HCPCS,outpatient,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,15,
..BMP N.MENINGITIDIS GRPS A/Y AG,1502348,CDM,300,RC,86403,HCPCS,outpatient,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,15,
..BMP N.MENINGITIDIS GRPS B/E.COLI K1 AG,1502349,CDM,300,RC,86403,HCPCS,outpatient,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,15,
..BMP N.MENINGITIDIS GRPS C/W 135 AG,1502347,CDM,300,RC,86403,HCPCS,outpatient,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,15,
..BMP S.PNEUMONIAE AG,1502346,CDM,300,RC,86403,HCPCS,outpatient,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,15,
..BMP STREP GROUP B AG,1502344,CDM,300,RC,86403,HCPCS,outpatient,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,15,
..C3,1502281,CDM,300,RC,86160,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,26.8,
..C4,1502282,CDM,300,RC,86160,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,26.8,
..DNA ANTIBODY,1502294,CDM,300,RC,86225,HCPCS,outpatient,,,33.33,20,,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,30,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.13,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.13,30,
..MARITAL SCREEN-F.,1500133,CDM,300,RC,,,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,92.44,
..MARITAL SCREEN-M & F,1500150,CDM,300,RC,,,outpatient,,,182.76,109.66,,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,164.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,115.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.45,164.48,
..MARITAL SCREEN-MALE,1500134,CDM,300,RC,,,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.4,72.04,
..MITOCHONDRIAL AB,1502292,CDM,300,RC,86255,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,26.8,
..MYOCARDIAL ANTIBODY,1502296,CDM,300,RC,86255,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,26.8,
..RETICULIN IGA ANTIBODY,1502291,CDM,300,RC,86255,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,26.8,
..RHEUMATOID FACTOR (RA),1502284,CDM,300,RC,86431,HCPCS,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.59,12.78,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1502290,CDM,300,RC,83516,HCPCS,outpatient,,,26.22,15.73,,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,23.6,
..SCL-70 ANTIBODY,1502289,CDM,300,RC,86235,HCPCS,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,39.83,
..SM ANTIBODY,1502287,CDM,300,RC,86235,HCPCS,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,39.83,
..SM/RNP ANTIBODY,1502288,CDM,300,RC,86235,HCPCS,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,39.83,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1502293,CDM,300,RC,83516,HCPCS,outpatient,,,26.22,15.73,,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,23.6,
..SS-A ANTIBODY,1502285,CDM,300,RC,86235,HCPCS,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,39.83,
..SS-B ANTIBODY,1502286,CDM,300,RC,86235,HCPCS,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,39.83,
..STRIATED MUSCLE AB,1502295,CDM,300,RC,86255,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,26.8,
..THYRIOD ANTIBODY,1502283,CDM,300,RC,86376,HCPCS,outpatient,,,35.78,21.47,,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,32.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.79,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.79,32.2,
.AMPHETAMINES (SERUM),150138,CDM,300,RC,82145,HCPCS,outpatient,,,376.18,225.71,,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,188.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.08,338.56,
.ANAEROBIC ORG ID,1502375,CDM,300,RC,87076,HCPCS,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.54,25.33,
"Complete blood cell count, with differential white blood cells, automated",1501701,CDM,300,RC,85025,HCPCS,outpatient,,,129.49,77.69,,97.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.29,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.29,116.54,
"Complete blood cell count, with differential white blood cells, automated",1501931,CDM,300,RC,85025,HCPCS,outpatient,,,84.46,50.68,,63.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,63.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,76.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.29,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.29,76.01,
"Complete blood count, automated",1502386,CDM,300,RC,85027,HCPCS,outpatient,,,22.66,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,20.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,20.39,
.DR. AXON COLLECTION FEE,1501915,CDM,300,RC,,,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.15,57.78,
.DRUG SCREEN I (TOX I),1501905,CDM,300,RC,80100,HCPCS,outpatient,,,97.81,58.69,,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.04,88.03,
.HER-2-NEU,1501450,CDM,300,RC,88365,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,106.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,235.29,
.HERPES SIMPLEX TYPE 2,1502035,CDM,300,RC,86696,HCPCS,outpatient,,,74.3,44.58,,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.54,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.54,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.68,66.87,
.HIV -1 AB,1502171,CDM,300,RC,86701,HCPCS,outpatient,,,35.78,21.47,,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.56,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.79,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.06,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,32.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.2,32.2,
.HIV -2 AB,1502172,CDM,300,RC,86702,HCPCS,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.95,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.95,49.42,
.LEUKOCYTE HISTAMINE RELEASE TEST,1502442,CDM,300,RC,8634390,HCPCS,outpatient,,,40.31,24.19,,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,36.28,
Blood test to assess for infection,1502385,CDM,300,RC,85007,HCPCS,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.08,13.91,
".MICROSOMAL ABS, EACH",1502440,CDM,300,RC,8637690,HCPCS,outpatient,,,40.31,24.19,,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,36.28,
.PROTEIN FRACTIONS/QUANTITATION CSF,1502372,CDM,300,RC,84166,HCPCS,outpatient,,,33.88,20.33,,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,30.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.45,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.45,30.49,
.SALMONELLA H TYPE A,1502360,CDM,300,RC,86768,HCPCS,outpatient,,,78.67,47.2,,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,70.8,
.SALMONELLA H TYPE B,1502361,CDM,300,RC,86768,HCPCS,outpatient,,,78.67,47.2,,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,70.8,
.SALMONELLA H TYPE D,1502362,CDM,300,RC,86768,HCPCS,outpatient,,,78.67,47.2,,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,70.8,
.SALMONELLA O TYPE D,1502364,CDM,300,RC,86768,HCPCS,outpatient,,,78.67,47.2,,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,70.8,
.SALMONELLA O TYPE VI,1502363,CDM,300,RC,86768,HCPCS,outpatient,,,78.67,47.2,,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,70.8,
.THYROGLOBILIN AB,1502441,CDM,300,RC,8680090,HCPCS,outpatient,,,40.31,24.19,,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,36.28,
.TOTAL PROTEIN CSF,1502371,CDM,300,RC,84157,HCPCS,outpatient,,,11.21,6.73,,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,10.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.24,10.09,
.TSH,1502439,CDM,300,RC,8444390,HCPCS,outpatient,,,40.31,24.19,,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.26,36.28,
"1,25 DIHYDROXY-VIT D",1500353,CDM,300,RC,82652,HCPCS,outpatient,,,465.23,279.14,,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,58.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,39.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,418.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,31.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.19,418.71,
17-Hydroxycorticosteroids,1500144,CDM,300,RC,83491,HCPCS,outpatient,,,160.63,96.38,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.5,144.57,
17-HYDROXYPROGESTERONE,1501309,CDM,300,RC,83498,HCPCS,outpatient,,,208.17,124.9,,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,41.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,41.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,187.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.01,187.35,
17-KETOGENIC & KETOS,1500129,CDM,300,RC,83582,HCPCS,outpatient,,,122.38,73.43,,91.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,91.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.65,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.53,110.14,
17-KETOSTEROIDS,1500170,CDM,300,RC,83586,HCPCS,outpatient,,,176.48,105.89,,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.05,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,158.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.37,158.83,
Blood test to monitor vitamin D levels,1501412,CDM,300,RC,82306,HCPCS,outpatient,,,240.4,144.24,,180.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,45.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,180.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.19,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,216.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.98,216.36,
5 HIAA 24 HOUR URINE,1500344,CDM,300,RC,83497,HCPCS,outpatient,,,95.07,57.04,,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.7,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,85.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.45,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.45,85.56,
5 HIAA RANDOM URINE,1502323,CDM,300,RC,83497,HCPCS,outpatient,,,46.44,27.86,,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.7,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,41.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.45,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.45,41.8,
5' NUCLEOTIDASE,1500130,CDM,300,RC,83915,HCPCS,outpatient,,,139.05,83.43,,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,125.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.04,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.04,125.15,
A. ALTERNATA IGE SPEC ALLERGEN (M6),1501207,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
A. FUMIGATUS IGE SPEC ALLERGEN (M3),1501208,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
A/G RATIO,1500002,CDM,300,RC,,,outpatient,,,111.73,67.04,,83.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,83.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.89,100.56,
Blood test to measure average blood glucose levels for past 2-3 months,1501519,CDM,300,RC,83036,HCPCS,outpatient,,,118.56,71.14,,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.82,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.9,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.87,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.87,106.7,
ABG PUNCTURE,2600081,CDM,300,RC,36600,HCPCS,outpatient,,,137.41,82.45,,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,29.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,123.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,1459.9,
ACCUCHECK,1750020,CDM,300,RC,82962,HCPCS,outpatient,,,21.31,12.79,,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.34,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,19.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.66,19.18,
ACCUCHECK,2500052,CDM,300,RC,82962,HCPCS,outpatient,,,22.66,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.34,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,20.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.66,20.39,
ACETAMINOPHEN (TYLENOL),1500249,CDM,300,RC,80143,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,93.63,
ACETONE (URINE),1500001,CDM,300,RC,82009,HCPCS,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.66,39.58,
ACETYCHOLINE RECEPTOR BLOCK ANTIBODY,1502115,CDM,300,RC,83519,HCPCS,outpatient,,,184.39,110.63,,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,165.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,165.95,
ACETYCHOLINE RECEPTOR MOD ANTIBODY,1502114,CDM,300,RC,83519,HCPCS,outpatient,,,295.31,177.19,,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,265.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,265.78,
ACETYLCHOLINE RECEPTOR ANTIBODY,1501285,CDM,300,RC,83519,HCPCS,outpatient,,,786.77,472.06,,590.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,590.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,708.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,590.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,708.09,
ACETYLCHOLINESTERASE,1501709,CDM,300,RC,82482,HCPCS,outpatient,,,167.19,100.31,,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,150.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.95,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.95,150.47,
ACID PHOSPHATASE,1500104,CDM,300,RC,84060,HCPCS,outpatient,,,69.66,41.8,,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,62.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.19,62.69,
ACTH LEVEL,1500156,CDM,300,RC,82024,HCPCS,outpatient,,,272.91,163.75,,204.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,58.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,204.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.01,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,39.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,245.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,204.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,31.28,90,,,fee schedule,90% UHC fee schedule for outpatient setting,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.28,245.62,
ACTIN ANTIBODY IgG,1500181,CDM,300,RC,86255,HCPCS,outpatient,,,228.38,137.03,,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,205.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,205.54,
"ACYLCARNITINE, PLASMA",1502059,CDM,300,RC,82017,HCPCS,outpatient,,,93.98,56.39,,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,84.58,
ADALIMUMAB ABS,1502393,CDM,300,RC,83520,HCPCS,outpatient,,,218.55,131.13,,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,196.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.99,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.99,196.7,
ADDITIONAL HIGH RESOLUTION STUDY,1501924,CDM,300,RC,88289,HCPCS,outpatient,,,281.39,168.83,,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,52.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,253.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,34.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.89,253.25,
ADDITIONAL IMMUNOS,1502152,CDM,300,RC,88341,HCPCS,outpatient,,,253.24,151.94,,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,69.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,52.33,90,,,fee schedule,90% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.33,227.92,
ADDITIONAL KARYOTYPES,1501925,CDM,300,RC,88280,HCPCS,outpatient,,,281.39,168.83,,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,34.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,253.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,33.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.11,253.25,
ADENOVIRUS,1500048,CDM,300,RC,87798,HCPCS,outpatient,,,71.03,42.62,,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,63.93,
ADENOVIRUS (CF),1500411,CDM,300,RC,86171,HCPCS,outpatient,,,93.7,56.22,,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.11,84.33,
ADENOVIRUS SMEAR,1500412,CDM,300,RC,87206,HCPCS,outpatient,,,93.7,56.22,,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.37,84.33,
ADSORPTION,1501738,CDM,300,RC,86978,HCPCS,outpatient,,,140.97,84.58,,105.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,126.87,
AF CULTURE PROGRESIVE,1501137,CDM,300,RC,87116,HCPCS,outpatient,,,110.36,66.22,,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,11.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,99.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.75,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.75,99.32,
Blood test to determine genetic material of certain infectious agents,1502373,CDM,300,RC,87801,HCPCS,outpatient,,,337.65,202.59,,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,91.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,59.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,71.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,303.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,56.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,56.86,303.89,
AFB CULTURE,1500137,CDM,300,RC,87116,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,11.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.75,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.75,98.09,
AFB DETECTION BY MTD,1501920,CDM,300,RC,87556,HCPCS,outpatient,,,173.2,103.92,,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,36.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,42.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,155.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.76,155.88,
AFB SMEAR,1500525,CDM,300,RC,87206,HCPCS,outpatient,,,112.01,67.21,,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,100.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.37,100.81,
ALBUMIN,1500003,CDM,300,RC,82040,HCPCS,outpatient,,,18.54,11.12,,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,16.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.01,16.69,
ALBUMIN 24 HR URINE W/O CREAT (4555),1502477,CDM,300,RC,8204390,HCPCS,outpatient,,,6.44,3.86,,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,5.8,
"ALBUMIN, PERITONEAL FLUID",1502474,CDM,300,RC,8204290,HCPCS,outpatient,,,5.55,3.33,,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.78,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.14,5,
ALBUTERAL LEVEL,1500521,CDM,300,RC,80299,HCPCS,outpatient,,,318.54,191.12,,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,286.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,286.69,
"ALCOHOL ETHYL, URINE RANDOM",1501287,CDM,300,RC,80320,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,315.94,
ALDOLASE,1500220,CDM,300,RC,82085,HCPCS,outpatient,,,92.61,55.57,,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.82,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.9,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,83.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.87,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.87,83.35,
ALDOSTERONE,1500110,CDM,300,RC,82088,HCPCS,outpatient,,,228.38,137.03,,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.98,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,62.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,41.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,205.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.01,205.54,
ALDOSTERONE 24HR UR,1502310,CDM,300,RC,82088,HCPCS,outpatient,,,162.28,97.37,,121.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.98,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,62.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,121.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,41.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,146.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.01,146.05,
ALDOSTERONE/PLASMA RENIN ACTIVITY RATIO,1502134,CDM,300,RC,82088,HCPCS,outpatient,,,166.1,99.66,,124.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.98,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,62.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,124.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,41.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,149.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.01,149.49,
ALK PHOSPHATASE (FRACTIONATED),1500278,CDM,300,RC,84080,HCPCS,outpatient,,,76.22,45.73,,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,68.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.97,68.6,
ALKALINE PHOSPHATASE,1500004,CDM,300,RC,84075,HCPCS,outpatient,,,90.42,54.25,,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,81.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,81.38,
ALLERGENS,1502129,CDM,300,RC,86003,HCPCS,outpatient,,,11.33,6.8,,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,10.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,10.2,
ALLERGY PANEL (UPPER RESPIRATORY),1501879,CDM,300,RC,86003,HCPCS,outpatient,,,282.48,169.49,,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,254.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,254.23,
ALLOPURINOL (ZYLOPRIM),1501896,CDM,300,RC,80299,HCPCS,outpatient,,,237.13,142.28,,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,213.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,213.42,
ALPHA 1 ANTITRYPSIN PHENOTYPE,1502399,CDM,300,RC,82104,HCPCS,outpatient,,,60.1,36.06,,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.91,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.71,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.91,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.71,54.09,
ALPHA 1 ANTITRYPSIN STOOL,1501293,CDM,300,RC,82103,HCPCS,outpatient,,,259.25,155.55,,194.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.47,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,194.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.89,233.33,
ALPHA I ANTITRYPSIN,1500347,CDM,300,RC,82103,HCPCS,outpatient,,,88.79,53.27,,66.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.47,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,66.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,79.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.89,79.91,
ALPHA SUBUNIT,1502043,CDM,300,RC,83519,HCPCS,outpatient,,,373.71,224.23,,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,336.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,336.34,
ALPHA-1-ANTITRYPSIN PHENOTYPE,1502325,CDM,300,RC,82104,HCPCS,outpatient,,,52.18,31.31,,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,46.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.91,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.71,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.91,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.71,46.96,
ALPHA-FETOPROTEIN (MATERNAL),1500200,CDM,300,RC,82105,HCPCS,outpatient,,,136.59,81.95,,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,122.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.58,122.93,
ALPHA-FETOPROTEIN (TUMOR MARKER),1500105,CDM,300,RC,82105,HCPCS,outpatient,,,136.59,81.95,,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,122.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.58,122.93,
Blood test to evaluate liver function,1501491,CDM,300,RC,84460,HCPCS,outpatient,,,106.54,63.92,,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.89,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,95.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.29,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.29,95.89,
ALTERNATIVE COMP PATHWAY ACT (58689),1502496,CDM,300,RC,8616290,HCPCS,outpatient,,,164.8,98.88,,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.77,148.32,
ALUMINUM,1500408,CDM,300,RC,82108,HCPCS,outpatient,,,121.57,72.94,,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.72,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.72,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.76,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,25.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,109.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.64,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.64,109.41,
AMIKACIN PEAK LEVEL,1500284,CDM,300,RC,80150,HCPCS,outpatient,,,93.98,56.39,,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.21,84.58,
AMIKACIN TROUGH LEVEL,1501284,CDM,300,RC,80150,HCPCS,outpatient,,,93.98,56.39,,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.21,84.58,
AMINO ACID,1501951,CDM,300,RC,82139,HCPCS,outpatient,,,634.6,380.76,,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,571.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,571.14,
AMINO ACID SCREEN,1500395,CDM,300,RC,82128,HCPCS,outpatient,,,168.83,101.3,,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.03,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.18,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,151.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.23,151.95,
AMINO AND ORGANIC ACID (URINE),1501821,CDM,300,RC,82136,HCPCS,outpatient,,,376.18,225.71,,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,338.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.89,338.56,
AMIODARONE,1501877,CDM,300,RC,80151,HCPCS,outpatient,,,346.4,207.84,,259.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,259.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,311.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,259.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,311.76,
AMITRIPTYLINE,1500250,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
AMMONIA,1500217,CDM,300,RC,82140,HCPCS,outpatient,,,22.66,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.86,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,20.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.8,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.8,20.39,
AMOEBA ANTIBODIES,1500483,CDM,300,RC,86753,HCPCS,outpatient,,,184.13,110.48,,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.94,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,165.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.04,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.04,165.72,
AMPHETAMINES (SERUM),1501837,CDM,300,RC,80324,HCPCS,outpatient,,,376.18,225.71,,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.56,338.56,
AMPLICATION,1501957,CDM,300,RC,83901,HCPCS,outpatient,,,175.66,105.4,,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,158.09,
AMPLIFICATION,1501830,CDM,300,RC,83898,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,217.1,
AMYLASE,1500005,CDM,300,RC,82150,HCPCS,outpatient,,,149.35,89.61,,112.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,112.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,134.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.25,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.25,134.42,
AMYLASE ISOENZYMES,1501292,CDM,300,RC,82664,HCPCS,outpatient,,,172.93,103.76,,129.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.95,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,52.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,129.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.49,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,62.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,155.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,49.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,61.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,61.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.82,155.64,
AMYLASE PLEURAL FLUID,1502056,CDM,300,RC,82150,HCPCS,outpatient,,,36.34,21.8,,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,32.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.25,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.25,32.71,
ANA IFA W/ REFLEX TO TITER,1500093,CDM,300,RC,86038,HCPCS,outpatient,,,51.5,30.9,,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.79,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.79,46.35,
ANA TITRE,1500185,CDM,300,RC,86256,HCPCS,outpatient,,,136.87,82.12,,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,123.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,123.18,
ANABOLIC STEROIDS,1501857,CDM,300,RC,80327,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.11,315.94,
ANCA ANTIBODY,1501371,CDM,300,RC,86255,HCPCS,outpatient,,,344.48,206.69,,258.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,258.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,310.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,310.03,
ANDROGEN,1500302,CDM,300,RC,84235,HCPCS,outpatient,,,212.54,127.52,,159.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,71.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,79.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,159.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,72.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,191.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,71.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,57.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,71.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,71.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.7,191.29,
ANDROSTENEDIONE LEVEL,1501434,CDM,300,RC,87152,HCPCS,outpatient,,,156.81,94.09,,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,141.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.27,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.27,141.13,
ANGIOTENSIN-1-CONV E,1500310,CDM,300,RC,82164,HCPCS,outpatient,,,144.24,86.54,,108.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.98,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,108.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.3,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,129.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.83,129.82,
ANTI BODY LEVEL 1,1500465,CDM,300,RC,86870,HCPCS,outpatient,,,425.1,255.06,,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,382.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,382.59,
ANTI BODY LEVEL 11,1500464,CDM,300,RC,86870,HCPCS,outpatient,,,425.1,255.06,,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,382.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,382.59,
ANTI BODY LEVEL III,1500466,CDM,300,RC,86870,HCPCS,outpatient,,,425.1,255.06,,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,382.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,382.59,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1501921,CDM,300,RC,83516,HCPCS,outpatient,,,83.33,50,,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,75,
ANTI DNA ANTIBODY (SINGLE STRAND),1500228,CDM,300,RC,86225,HCPCS,outpatient,,,87.97,52.78,,65.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,65.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,79.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.13,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.13,79.17,
ANTI DS DNA,1500433,CDM,300,RC,86225,HCPCS,outpatient,,,81.13,48.68,,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.13,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.13,73.02,
ANTI GLOMERLUAR BASEMENT MEMBRANE,1500261,CDM,300,RC,86255,HCPCS,outpatient,,,233.56,140.14,,175.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,175.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,210.2,
ANTI GM 1 TRIAD AUTO ANTIBODY,1501399,CDM,300,RC,83520,HCPCS,outpatient,,,750.16,450.1,,562.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,600.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,562.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,675.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,562.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.99,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.99,675.14,
Blood test indicating infection with Hepatitis B,1500328,CDM,300,RC,86704,HCPCS,outpatient,,,72.68,43.61,,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,65.41,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1501874,CDM,300,RC,83516,HCPCS,outpatient,,,106.28,63.77,,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,95.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,95.65,
ANTI SACCHAROMYCES CEREVISIAE,1502121,CDM,300,RC,86671,HCPCS,outpatient,,,619.85,371.91,,464.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,495.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,464.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.74,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,557.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,464.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,464.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.93,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.93,557.87,
ANTI-CARDIOLIPIN ANTIBODY,1501300,CDM,300,RC,86317,HCPCS,outpatient,,,163.64,98.18,,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,147.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.14,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.14,147.28,
ANTI-DIURETIC HORMONE,1501409,CDM,300,RC,84588,HCPCS,outpatient,,,264.16,158.5,,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,34.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,237.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.5,237.74,
ANTI-ENA,1500350,CDM,300,RC,86235,HCPCS,outpatient,,,314.98,188.99,,236.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,236.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,283.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,236.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,283.48,
ANTI-INSULIN ANTIBODY,1501909,CDM,300,RC,86337,HCPCS,outpatient,,,225.11,135.07,,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.83,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,202.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.34,202.6,
ANTI-JO (1) ANTIBODY,1501297,CDM,300,RC,86331,HCPCS,outpatient,,,57.09,34.25,,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,51.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,51.38,
ANTI-MICROSOMAL THYROID ANTIBODIES,1501319,CDM,300,RC,86376,HCPCS,outpatient,,,296.4,177.84,,222.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,222.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,266.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,222.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.79,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.79,266.76,
ANTI-MULLERIAN HORMONE,1502125,CDM,300,RC,83520,HCPCS,outpatient,,,147.52,88.51,,110.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,110.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,132.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.99,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.99,132.77,
ANTI-MULLERIN HORMONE,1502475,CDM,300,RC,8352090,HCPCS,outpatient,,,51.5,30.9,,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,46.35,
ANTI-NEURONAL CELL ANTIBODIES,1502033,CDM,300,RC,83520,HCPCS,outpatient,,,421.8,253.08,,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,337.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,379.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.99,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.99,379.62,
ANTI-PANCREATIC (ISLET CELL ANTIBODY),1501337,CDM,300,RC,86341,HCPCS,outpatient,,,87.14,52.28,,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.24,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,78.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.09,90,,,fee schedule,90% UHC fee schedule for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.09,78.43,
Blood test to determine cause of inappropriate blood clot formation,1501421,CDM,300,RC,86147,HCPCS,outpatient,,,125.94,75.56,,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,25.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,113.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.62,113.35,
ANTI-RNP,1501763,CDM,300,RC,86235,HCPCS,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,65.64,
ANTI-SMITH,1501765,CDM,300,RC,86235,HCPCS,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,65.64,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1501411,CDM,300,RC,83516,HCPCS,outpatient,,,94.52,56.71,,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,85.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,85.07,
ANTI-SSA/SSB,1501496,CDM,300,RC,86235,HCPCS,outpatient,,,139.05,83.43,,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,125.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,125.15,
ANTI-STRAITED MUSCLE ANTIBODY,1501880,CDM,300,RC,86255,HCPCS,outpatient,,,105.45,63.27,,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,94.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,94.91,
ANTI-STREPTOLYSIN (ASO),1500006,CDM,300,RC,86060,HCPCS,outpatient,,,138.5,83.1,,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.44,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,124.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.91,124.65,
ANTI-THYROGLOBULIN,1500178,CDM,300,RC,86800,HCPCS,outpatient,,,66.65,39.99,,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,59.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.89,59.99,
ANTI-THYROID ANTIBOD,1500388,CDM,300,RC,86376,HCPCS,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.79,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.79,72.04,
ANTI-XA,1502130,CDM,300,RC,85520,HCPCS,outpatient,,,270.46,162.28,,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,243.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.6,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.6,243.41,
ANTIBODIES TO HTLV-3,1500399,CDM,300,RC,86689,HCPCS,outpatient,,,150.26,90.16,,112.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,112.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.66,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,135.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.68,135.23,
ANTIBODY COATED BACT,1500348,CDM,300,RC,86609,HCPCS,outpatient,,,169.65,101.79,,127.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,127.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,152.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,152.69,
ANTIBODY ELUTION,1501311,CDM,300,RC,86860,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,235.29,
ANTIBODY ID & TITER,1500186,CDM,300,RC,86870,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,417.97,
ANTINEUTROPHILIC CYSTOPLASMIC ANTIBODIES,1501011,CDM,300,RC,86317,HCPCS,outpatient,,,308.15,184.89,,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,277.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.14,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.14,277.34,
ANTIPHOSPHOLIPID SYNDROME DX PANEL,1502142,CDM,300,RC,85613,HCPCS,outpatient,,,249.15,149.49,,186.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,186.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.62,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,224.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.49,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.49,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.76,224.24,
ANTIPLATELET ANTIBOD,1500403,CDM,300,RC,86022,HCPCS,outpatient,,,286.84,172.1,,215.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,215.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,258.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.88,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.88,258.16,
ANTITHROMBIN III,1500476,CDM,300,RC,85300,HCPCS,outpatient,,,289.57,173.74,,217.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,217.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.1,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,217.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.6,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.6,260.61,
APOLIPOPROTEIN B-100,1502027,CDM,300,RC,82172,HCPCS,outpatient,,,77.58,46.55,,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,69.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.08,69.82,
APOLIPOPROTEIN EACH,1501882,CDM,300,RC,82172,HCPCS,outpatient,,,107.64,64.58,,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,96.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.08,96.88,
APT,1500300,CDM,300,RC,83033,HCPCS,outpatient,,,65.56,39.34,,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.4,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.48,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.48,59,
ARSENIC,1502487,CDM,300,RC,8217590,HCPCS,outpatient,,,18.54,11.12,,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.69,
ARSENIC LEVEL,1500246,CDM,300,RC,82175,HCPCS,outpatient,,,186.85,112.11,,140.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,140.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.34,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,168.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,140.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.36,168.17,
ASA(SALICYLATE FOR SEND OUT ONLY),1501488,CDM,300,RC,80329,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.66,315.94,
ASCENDIN-AMOXAPINE,1500458,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
ASCORBIC ACID LEVEL,1500260,CDM,300,RC,82180,HCPCS,outpatient,,,214.99,128.99,,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,193.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.01,193.49,
ASPERGILLUS ANTIBODY,1502099,CDM,300,RC,86606,HCPCS,outpatient,,,246.95,148.17,,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,222.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.2,222.26,
ASPERGILLUS lgG ANTIBODY,1501834,CDM,300,RC,86606,HCPCS,outpatient,,,383.55,230.13,,287.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,287.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,345.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,287.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.2,345.2,
ASPRIN,1501487,CDM,300,RC,80329,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.66,315.94,
ATIVAN,1501414,CDM,300,RC,80324,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.56,315.94,
AUSTRALIAN ANTIGEN,1500094,CDM,300,RC,87449,HCPCS,outpatient,,,251.05,150.63,,188.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,188.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,225.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,225.95,
AUTOAGGLUTINATION,1501725,CDM,300,RC,86940,HCPCS,outpatient,,,69.66,41.8,,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.4,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.53,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,62.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.1,62.69,
AVENTYL,1501506,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
AVIAN HP PANEL,1502168,CDM,300,RC,86331,HCPCS,outpatient,,,393.93,236.36,,295.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,295.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,354.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,295.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,354.54,
B CELLS TOTAL COUNT,1502459,CDM,300,RC,8635590,HCPCS,outpatient,,,31.93,19.16,,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,28.74,
B. BURGDORFERI AB IGG,1501175,CDM,300,RC,8661790,HCPCS,outpatient,,,55.73,33.44,,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,50.16,
B. BURGDORFERI AB IGM,1501176,CDM,300,RC,8661790,HCPCS,outpatient,,,55.73,33.44,,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,50.16,
B1 ASSESSMENT (VITAMIN),1501125,CDM,300,RC,84425,HCPCS,outpatient,,,136.31,81.79,,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,122.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.2,122.68,
Blood test to measure B-12,1500095,CDM,300,RC,82607,HCPCS,outpatient,,,49.44,29.66,,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.21,44.5,
Blood test to measure B-12,1500096,CDM,300,RC,82607,HCPCS,outpatient,,,49.44,29.66,,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.21,44.5,
BAC. ANTIG. PAN.-CIE,1500345,CDM,300,RC,87449,HCPCS,outpatient,,,144.79,86.87,,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,130.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,130.31,
Test of a wound for type of bacterial infection,1502108,CDM,300,RC,87077,HCPCS,outpatient,,,191.51,114.91,,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,172.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.54,172.36,
BACTERIAL MENINGITIS ANTIGEN (CSF),1501437,CDM,300,RC,86403,HCPCS,outpatient,,,169.1,101.46,,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,152.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,152.19,
BAHIA GRASS IGE SPEC ALLERGEN (G17),1501209,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
Testing for presence of drug,1500242,CDM,300,RC,80307,HCPCS,outpatient,,,86.05,51.63,,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,80.78,
BARBITUATES URINE,1500243,CDM,300,RC,80345,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.36,315.94,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1501970,CDM,300,RC,83516,HCPCS,outpatient,,,1535.55,921.33,,1151.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1228.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1151.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1382,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1151.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1151.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1151.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1151.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,1382,
BASIC CELLULAR IMMUNE PROFILE,1501364,CDM,300,RC,86360,HCPCS,outpatient,,,96.16,57.7,,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,71.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.79,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,47.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,71.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,71.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.05,86.54,
Basic metabolic panel,1501033,CDM,300,RC,80048,HCPCS,outpatient,,,95.79,57.47,,71.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.85,86.21,
Blood test to screen for antibodies that could harm red blood cells,1500111,CDM,300,RC,86850,HCPCS,outpatient,,,63.86,38.32,,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,57.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.91,57.47,
BB BLOOD TYPE AND RH,1500013,CDM,300,RC,86900,HCPCS,outpatient,,,144.2,86.52,,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,129.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.42,132.76,
BB DIRECT COOMBS,1500032,CDM,300,RC,86880,HCPCS,outpatient,,,112.01,67.21,,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,100.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.37,100.81,
BB INDIRECT COOMBS,1500046,CDM,300,RC,86886,HCPCS,outpatient,,,74.86,44.92,,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,179.8,
BB IRRIDATION OF BLOOD PRODUCTS,1501360,CDM,300,RC,86945,HCPCS,outpatient,,,132.5,79.5,,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,43.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,43.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.8,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,119.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,119.25,
BCR ABL,1501827,CDM,300,RC,81206,HCPCS,outpatient,,,666.29,399.77,,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,213.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,119.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.56,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,167.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,599.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,132.8,90,,,fee schedule,90% UHC fee schedule for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,599.66,
BENCE JONES PROTEIN (17404X),1500147,CDM,300,RC,86334,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,34.13,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.1,34.13,
Testing for presence of drug,1502041,CDM,300,RC,80307,HCPCS,outpatient,,,38.8,23.28,,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,34.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.1,80.78,
BERMUDA GRASS IGE SPEC ALLERGEN (G2),1501210,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
"BETA 2 GLYCOPROTEIN (A,G,M)",1502163,CDM,300,RC,86146,HCPCS,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,25.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.62,96.63,
BETA 2 MICROGLOBLULIN,1500477,CDM,300,RC,82232,HCPCS,outpatient,,,174.3,104.58,,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.03,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.73,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,156.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.1,156.87,
BETA 2 TRANSFERRIN,1502136,CDM,300,RC,86335,HCPCS,outpatient,,,969.25,581.55,,726.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,44.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,726.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.83,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,29.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,872.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,726.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.78,872.33,
BETA D GLUCAN,1502392,CDM,300,RC,87449,HCPCS,outpatient,,,245.86,147.52,,184.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,184.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,221.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,184.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,221.27,
BETA HYDROXYBUTERATE,1502407,CDM,300,RC,8201090,HCPCS,outpatient,,,67.75,40.65,,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,60.98,
BICARBONATE (SERUM),1501818,CDM,300,RC,82374,HCPCS,outpatient,,,163.91,98.35,,122.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,122.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.97,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,147.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.95,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.95,147.52,
Manual urinalysis test with examination using microscope,1500089,CDM,300,RC,81000,HCPCS,outpatient,,,25.41,15.25,,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,22.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.26,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.26,22.87,
Measurement of direct bilirubin,1500008,CDM,300,RC,82248,HCPCS,outpatient,,,92.06,55.24,,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,82.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.07,82.85,
Measurement of direct bilirubin,1501010,CDM,300,RC,82248,HCPCS,outpatient,,,79.31,47.59,,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,71.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.07,71.38,
BILIRUBIN INDIRECT,1500009,CDM,300,RC,,,outpatient,,,16.67,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,15,
BILIRUBIN TOTAL,1500010,CDM,300,RC,82247,HCPCS,outpatient,,,123.2,73.92,,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.07,110.88,
BIRCH IGE SPEC ALLERGEN (T3),1501211,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
BKV BY PCR,1501900,CDM,300,RC,87799,HCPCS,outpatient,,,744.42,446.65,,558.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,595.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,158.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,158.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,558.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,43.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,669.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,558.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,558.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,152.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,152.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.7,669.98,
BLEEDING TIME,1500011,CDM,300,RC,85002,HCPCS,outpatient,,,83.59,50.15,,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,75.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.91,75.23,
BLOOD ALCOHOL,1500107,CDM,300,RC,80320,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,93.63,
BLOOD ALCOHOL (REF LAB),1501816,CDM,300,RC,80320,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,315.94,
Collection of venous blood by venipuncture,1500332,CDM,300,RC,36415,HCPCS,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.43,12.78,
BLOOD FREIGHT,1500468,CDM,300,RC,86999,HCPCS,outpatient,,,11.99,7.19,,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,2.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,10.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.46,28.54,
Blood test used to diagnose heart failure,1501813,CDM,300,RC,83880,HCPCS,outpatient,,,143.17,85.9,,107.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,107.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,40.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,128.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,31.8,90,,,fee schedule,90% UHC fee schedule for outpatient setting,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,39.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.8,128.85,
"BORDETELLA PERTUSIS ANTIBODIES, IGM",1502080,CDM,300,RC,86615,HCPCS,outpatient,,,391.47,234.88,,293.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,293.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,352.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,293.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,352.32,
BORDETELLA PERTUSIS IGG & IGA,1502081,CDM,300,RC,86615,HCPCS,outpatient,,,704.53,422.72,,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,634.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,634.08,
Test of body fluid other than blood to assess for bacteria,1500562,CDM,300,RC,87070,HCPCS,outpatient,,,81.47,48.88,,61.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,61.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,73.32,
BORRELIA BURGDORFERI ANTIBODIES,1501518,CDM,300,RC,86618,HCPCS,outpatient,,,230.29,138.17,,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,207.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.8,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.8,207.26,
BROMIDE,1500124,CDM,300,RC,80299,HCPCS,outpatient,,,99.71,59.83,,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,89.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,89.74,
BRUCELLOSIS ANTIBODIES,1500291,CDM,300,RC,86000,HCPCS,outpatient,,,47.8,28.68,,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,43.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,43.02,
BSP,1500014,CDM,300,RC,84382,HCPCS,outpatient,,,97.25,58.35,,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.63,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.93,87.53,
BULLOUS PEMPHIGOID ANTIBODY BP180,1502449,CDM,300,RC,8352090,HCPCS,outpatient,,,20.16,12.1,,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.08,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.13,18.14,
BUN Random Urine,1501373,CDM,300,RC,84540,HCPCS,outpatient,,,79.77,47.86,,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,71.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.5,71.79,
"BUN, 24 HR URINE",1502074,CDM,300,RC,84540,HCPCS,outpatient,,,79.77,47.86,,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,71.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.5,71.79,
"BUN, SERUM",1500015,CDM,300,RC,84520,HCPCS,outpatient,,,109.18,65.51,,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.2,98.26,
C DIFF TOXIN B PCR,1502357,CDM,300,RC,87493,HCPCS,outpatient,,,119.48,71.69,,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,107.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.48,107.53,
C REACTIVE PROTEIN-H,1500183,CDM,300,RC,86140,HCPCS,outpatient,,,140.08,84.05,,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,126.07,
C TELOPEPTIDE,1502165,CDM,300,RC,82523,HCPCS,outpatient,,,76.49,45.89,,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.05,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,68.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.13,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.13,68.84,
C-PEPTIDE,1501318,CDM,300,RC,84681,HCPCS,outpatient,,,658.1,394.86,,493.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,493.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.28,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,592.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,493.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,493.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,592.29,
C-TELOPEPTIDE (17406),1502063,CDM,300,RC,82523,HCPCS,outpatient,,,106.28,63.77,,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.05,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,95.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.13,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.13,95.65,
C-TERMINAL PARATHYROID HORMONE,1500502,CDM,300,RC,83970,HCPCS,outpatient,,,168.28,100.97,,126.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,62.95,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.95,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,126.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.06,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,42.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,151.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.44,90,,,fee schedule,90% UHC fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.44,151.45,
C. HERBARUM IGE SPEC ALLERGEN (M2),1501213,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
C. TRACHOMATIS AMP PROBE,1502421,CDM,300,RC,8749190,HCPCS,outpatient,,,42.44,25.46,,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,38.2,
C1 COMPLEMENT,1500307,CDM,300,RC,86160,HCPCS,outpatient,,,198.6,119.16,,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,178.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,178.74,
C1 ESTERASE INHIBITOR,1500479,CDM,300,RC,86160,HCPCS,outpatient,,,136.05,81.63,,102.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,102.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,122.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,122.45,
C1Q COMPLIMENT,1502005,CDM,300,RC,86160,HCPCS,outpatient,,,99.16,59.5,,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,89.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,89.24,
C2 COMPLEMENT,1500308,CDM,300,RC,86160,HCPCS,outpatient,,,208.71,125.23,,156.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,156.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,187.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,187.84,
C3 COMPLEMENT,1500113,CDM,300,RC,86160,HCPCS,outpatient,,,128.12,76.87,,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,115.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,115.31,
C3-C4 COMPLEMENT,1500274,CDM,300,RC,86161,HCPCS,outpatient,,,134.68,80.81,,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,121.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,121.21,
C4 COMP.,1500203,CDM,300,RC,86160,HCPCS,outpatient,,,142.33,85.4,,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,128.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,128.1,
Blood test to monitor for cancer,1500480,CDM,300,RC,86304,HCPCS,outpatient,,,213.09,127.85,,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,191.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,191.78,
Blood test to monitor breast cancer,1501375,CDM,300,RC,86300,HCPCS,outpatient,,,95.88,57.53,,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,86.29,
CA 19-9,1501424,CDM,300,RC,86301,HCPCS,outpatient,,,104.91,62.95,,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,94.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,94.42,
Blood test to monitor breast cancer,1501410,CDM,300,RC,86300,HCPCS,outpatient,,,124.03,74.42,,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,111.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,111.63,
CADMIUM LEVEL,1501904,CDM,300,RC,82300,HCPCS,outpatient,,,94.26,56.56,,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.36,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.15,90,,,fee schedule,90% UHC fee schedule for outpatient setting,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.15,84.83,
CALCITONIN,1500402,CDM,300,RC,82308,HCPCS,outpatient,,,270.46,162.28,,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,40.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,40.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,243.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.7,243.41,
CALCIUM,1500016,CDM,300,RC,82310,HCPCS,outpatient,,,121.01,72.61,,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.18,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.18,108.91,
CALCIUM - IONIZED,1501433,CDM,300,RC,82330,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.08,106.47,
CALCIUM (URINE),1502003,CDM,300,RC,82340,HCPCS,outpatient,,,29.23,17.54,,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.89,26.31,
CALCULI ANALYSIS,1500153,CDM,300,RC,82360,HCPCS,outpatient,,,162.54,97.52,,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,146.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,146.29,
CALIFORNIA ENCEPHALITIS IGG,1502426,CDM,300,RC,8665190,HCPCS,outpatient,,,43.5,26.1,,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,39.15,
CALIFORNIA ENCEPHALITIS IGM,1502427,CDM,300,RC,8665190,HCPCS,outpatient,,,43.5,26.1,,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,39.15,
CALPROTECTIN,1502133,CDM,300,RC,83993,HCPCS,outpatient,,,516.59,309.95,,387.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,387.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,464.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,387.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.9,464.93,
CANCER ANTIGEN,1500554,CDM,300,RC,86316,HCPCS,outpatient,,,81.16,48.7,,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,73.04,
Blood test to monitor breast cancer,1501306,CDM,300,RC,86300,HCPCS,outpatient,,,117.19,70.31,,87.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,87.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,105.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,105.47,
CANCER ANTIGEN CA 19-9,1501334,CDM,300,RC,86301,HCPCS,outpatient,,,211.72,127.03,,158.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,158.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,190.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,158.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,190.55,
CANDIDA ALBICANS ABS IGA,1502469,CDM,300,RC,8662890,HCPCS,outpatient,,,37.08,22.25,,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,33.37,
CANDIDA ALBICANS ABS IGG,1502470,CDM,300,RC,8662890,HCPCS,outpatient,,,37.08,22.25,,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,33.37,
CANDIDA ALBICANS ABS IGM,1502471,CDM,300,RC,8662890,HCPCS,outpatient,,,37.08,22.25,,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.6,33.37,
CANDIDA ANTIGEN,1500409,CDM,300,RC,86628,HCPCS,outpatient,,,329.19,197.51,,246.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,246.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,296.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,246.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.73,296.27,
CANNABINOL,1502038,CDM,300,RC,80349,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,315.94,
CARBAMEZEPINE,1501484,CDM,300,RC,80156,HCPCS,outpatient,,,213.63,128.18,,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.86,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,192.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.8,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.8,192.27,
CARBON MONOXIDE,1501502,CDM,300,RC,82375,HCPCS,outpatient,,,71.03,42.62,,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,63.93,
CARBON MONOXIDE QUANTITATIVE,2600086,CDM,300,RC,82375,HCPCS,outpatient,,,19.57,11.74,,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,17.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,17.61,
CARBOXYHEMOGLOBIN,1500306,CDM,300,RC,82375,HCPCS,outpatient,,,71.03,42.62,,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.36,63.93,
CARDIO IQ LIPID PANEL,1502143,CDM,300,RC,83704,HCPCS,outpatient,,,127.85,76.71,,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,34.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,115.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.69,90,,,fee schedule,90% UHC fee schedule for outpatient setting,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,34.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.69,115.07,
Blood test to determine cause of inappropriate blood clot formation,1501833,CDM,300,RC,86147,HCPCS,outpatient,,,653.45,392.07,,490.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,522.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,490.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,25.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,588.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,490.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,490.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.62,588.11,
CARDIOLIPIN ANTIBODY (IGA) (4661),1502465,CDM,300,RC,8614790,HCPCS,outpatient,,,6.18,3.71,,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,5.56,
CARISOPRODOL AND METABOLITE (15450),1502445,CDM,300,RC,8036990,HCPCS,outpatient,,,120.94,72.56,,90.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,60.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.78,108.85,
CARNITINE,1501966,CDM,300,RC,82379,HCPCS,outpatient,,,207.9,124.74,,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,187.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,187.11,
CAROTENE,1500112,CDM,300,RC,82380,HCPCS,outpatient,,,123.75,74.25,,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,111.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.47,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.47,111.38,
CAT DANDER IGE SPEC ALLERGEN (E1),1501212,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
CAT SCRATCH FEVER,1501404,CDM,300,RC,86611,HCPCS,outpatient,,,220.45,132.27,,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,198.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.24,198.41,
CATECHOLAMINES FRACTIONATED URINE,1501355,CDM,300,RC,82382,HCPCS,outpatient,,,254.06,152.44,,190.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,190.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,228.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,190.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,228.65,
"CATECHOLAMINES,TOTAL",1500167,CDM,300,RC,82382,HCPCS,outpatient,,,236.58,141.95,,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,212.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,212.92,
"Complete blood count, automated",1501932,CDM,300,RC,85027,HCPCS,outpatient,,,22.66,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,20.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,20.39,
Blood test to diagnose rheumatoid arthritis,1501973,CDM,300,RC,86200,HCPCS,outpatient,,,73.77,44.26,,55.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.49,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.49,66.39,
CD4,1501352,CDM,300,RC,86361,HCPCS,outpatient,,,207.34,124.4,,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.81,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,186.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.69,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.69,186.61,
CEA,1500109,CDM,300,RC,82378,HCPCS,outpatient,,,140.42,84.25,,105.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,105.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.35,126.38,
CELL COUNT AND DIFF (BODY FLUID),1500523,CDM,300,RC,89050,HCPCS,outpatient,,,48.64,29.18,,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,43.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.83,43.78,
CELL COUNT AND DIFF (CSF),1500075,CDM,300,RC,89050,HCPCS,outpatient,,,76.77,46.06,,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,69.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.83,69.09,
CELL SEPARATION,1501718,CDM,300,RC,86972,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,235.29,
CELLULAR IMMUNE PROFILE,1501304,CDM,300,RC,86360,HCPCS,outpatient,,,661.37,396.82,,496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,71.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.79,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,47.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,595.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,71.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,71.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,46.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.05,595.23,
Blood test to determine autoimmune disorders,1501919,CDM,300,RC,86039,HCPCS,outpatient,,,132.5,79.5,,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.06,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,119.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.04,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.04,119.25,
CERULOPLASMIN,1500209,CDM,300,RC,82390,HCPCS,outpatient,,,112.83,67.7,,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,101.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.7,101.55,
CH 50,1501425,CDM,300,RC,86162,HCPCS,outpatient,,,90.16,54.1,,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,81.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.79,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.79,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.46,81.14,
CH50 COMPLEMENT TOTAL,1500159,CDM,300,RC,86162,HCPCS,outpatient,,,215.27,129.16,,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,193.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.79,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.79,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.46,193.74,
CHLAMYDIA AB IGA,1502482,CDM,300,RC,8663190,HCPCS,outpatient,,,14.42,8.65,,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,12.98,
CHLAMYDIA AB IGA,1502483,CDM,300,RC,8663290,HCPCS,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.73,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,13.91,
CHLAMYDIA AB IGG,1502481,CDM,300,RC,8663190,HCPCS,outpatient,,,14.42,8.65,,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,12.98,
CHLAMYDIA ANTIBODY,1500481,CDM,300,RC,86631,HCPCS,outpatient,,,239.03,143.42,,179.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,179.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.07,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.05,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,215.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,179.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.58,215.13,
CHLAMYDIA CF,1500311,CDM,300,RC,86631,HCPCS,outpatient,,,113.92,68.35,,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.07,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.05,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,102.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.58,102.53,
CHLAMYDIA CULTURE,1500440,CDM,300,RC,87110,HCPCS,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.68,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.88,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.68,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.88,72.04,
Test that detects Chlamydia,1501978,CDM,300,RC,87491,HCPCS,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,72.04,
CHLAMYDIA IGG ANTIBODIES,1501380,CDM,300,RC,86631,HCPCS,outpatient,,,55.91,33.55,,41.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,41.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.07,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.05,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.58,50.32,
Blood test to determine genetic material of certain infectious agents,1501871,CDM,300,RC,87801,HCPCS,outpatient,,,158.44,95.06,,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,91.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,59.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,71.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,142.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,56.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,56.86,142.6,
CHLORAMPHENICOL LEVE,1500294,CDM,300,RC,82415,HCPCS,outpatient,,,162.54,97.52,,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.47,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,146.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.26,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.26,146.29,
"CHLORIDE, 24 HR URINE",1502073,CDM,300,RC,82436,HCPCS,outpatient,,,39.06,23.44,,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.86,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.66,35.15,
"CHLORIDE, Random Urine",1502052,CDM,300,RC,82436,HCPCS,outpatient,,,39.06,23.44,,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.86,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.66,35.15,
"CHLORIDE, SERUM",1500020,CDM,300,RC,82435,HCPCS,outpatient,,,85.23,51.14,,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.98,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,76.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.73,76.71,
CHOLESTEROL,1500021,CDM,300,RC,82465,HCPCS,outpatient,,,121.01,72.61,,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.65,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.43,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.53,108.91,
CHOLESTEROL ESTERS,1500232,CDM,300,RC,84999,HCPCS,outpatient,,,161.18,96.71,,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,145.06,
CHOLINESTERASE RBC,1500158,CDM,300,RC,82482,HCPCS,outpatient,,,149.98,89.99,,112.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,112.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,134.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.95,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.95,134.98,
CHOLINESTERASE SERUM,1500187,CDM,300,RC,82480,HCPCS,outpatient,,,129.76,77.86,,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.37,116.78,
CHROMIUM BLOOD,1502048,CDM,300,RC,82495,HCPCS,outpatient,,,258.16,154.9,,193.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,193.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.68,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,232.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,193.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.43,232.34,
CHROMIUM FLUID,1502381,CDM,300,RC,82495,HCPCS,outpatient,,,271.27,162.76,,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.68,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,244.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.43,244.14,
CHROMOSOME ANAL AMNIO CELLS 6-12 COLS,1502418,CDM,300,RC,8826990,HCPCS,outpatient,,,460.43,276.26,,345.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,345.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,414.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,345.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,230.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.34,414.39,
CHROMOSOME KAROTYPES,1501804,CDM,300,RC,88262,HCPCS,outpatient,,,1328.75,797.25,,996.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1063,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,163.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,190.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,190.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,996.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.43,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,127.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1195.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,996.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,188.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,101.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,188.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,125.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,101.65,1195.88,
Blood test to detect heart enzymes,1501389,CDM,300,RC,82553,HCPCS,outpatient,,,28.84,17.3,,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.5,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.5,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.36,25.96,
CLOMIPRAMINE,1501917,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
CLONAZEPAM,1501435,CDM,300,RC,80346,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,315.94,
CLOSTRIDIUM DIFFICILE,1501803,CDM,300,RC,87493,HCPCS,outpatient,,,119.48,71.69,,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,107.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.48,107.53,
CLOT RETRACTION,1500022,CDM,300,RC,85170,HCPCS,outpatient,,,44.81,26.89,,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.19,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,40.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.48,40.33,
CLOTTING TIME,1500023,CDM,300,RC,85002,HCPCS,outpatient,,,174.41,104.65,,130.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,130.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,156.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.91,156.97,
CLOZARIL,1501331,CDM,300,RC,80159,HCPCS,outpatient,,,287.94,172.76,,215.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,215.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.55,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,259.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.33,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.33,259.15,
"Blood test, comprehensive group of blood chemicals",1501489,CDM,300,RC,80053,HCPCS,outpatient,,,279.2,167.52,,209.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,209.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,251.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,209.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.55,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.55,251.28,
CMV (CYTOMEGALOVIRUS) BY PCR,1501838,CDM,300,RC,87496,HCPCS,outpatient,,,513.58,308.15,,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,462.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,462.22,
Blood test to monitor for cytomegalovirus,1500272,CDM,300,RC,86644,HCPCS,outpatient,,,152.71,91.63,,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,137.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,137.44,
Blood test to monitor for cytomegalovirus,1501730,CDM,300,RC,86644,HCPCS,outpatient,,,63.38,38.03,,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,57.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,57.04,
CO2,1500024,CDM,300,RC,82374,HCPCS,outpatient,,,82.5,49.5,,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.97,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.95,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.95,74.25,
COBALT,1500007,CDM,300,RC,83018,HCPCS,outpatient,,,199.43,119.66,,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,179.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.78,179.49,
COBALT FLUID,1502382,CDM,300,RC,83018,HCPCS,outpatient,,,318.54,191.12,,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,286.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.78,286.69,
Testing for presence of drug,1502040,CDM,300,RC,80307,HCPCS,outpatient,,,38.8,23.28,,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,34.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.1,80.78,
COCCIDIODES ABS CP,1502390,CDM,300,RC,86635,HCPCS,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.53,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.29,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.29,17.53,
COCCIDIODES ABS ID,1502391,CDM,300,RC,86635,HCPCS,outpatient,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.53,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,12.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.29,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.29,17.53,
COCKROACH IGE SPEC ALLERGEN (I6),1501214,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
COLD AGGLUTININS,1500025,CDM,300,RC,86157,HCPCS,outpatient,,,118.56,71.14,,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.53,106.7,
COLL FEE URINE DRUG SCREEN - COC,1501430,CDM,300,RC,,,outpatient,,,35.78,21.47,,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.33,32.2,
Collection of venous blood by venipuncture,1501861,CDM,300,RC,36415,HCPCS,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.43,17.22,
COLLECTION FEE-DRUG SCREEN 9 PANEL,1501998,CDM,300,RC,,,outpatient,,,58.46,35.08,,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,36.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.98,52.61,
COM RAGWEED SHORT IGE SPEC ALLERGEN (W,1501215,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
Testing for presence of drug,1500459,CDM,300,RC,80307,HCPCS,outpatient,,,368.25,220.95,,276.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,276.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,331.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,276.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,331.43,
COMP. FIX-MYCOPLASMA,1500352,CDM,300,RC,86171,HCPCS,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.11,97.11,
COMP. VIRAL CULTURE,1500389,CDM,300,RC,87250,HCPCS,outpatient,,,182.21,109.33,,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,163.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.84,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.84,163.99,
COMPATIBILITY SCREEN,1501732,CDM,300,RC,86904,HCPCS,outpatient,,,191.78,115.07,,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,172.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,172.6,
COMPL FIXATION TITER,1500225,CDM,300,RC,86171,HCPCS,outpatient,,,154.89,92.93,,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.11,139.4,
"Blood test, comprehensive group of blood chemicals",1500370,CDM,300,RC,80053,HCPCS,outpatient,,,83.43,50.06,,62.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,75.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.55,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.55,75.09,
CONCENTRATION (AFB),1501840,CDM,300,RC,87015,HCPCS,outpatient,,,74.58,44.75,,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.41,67.12,
CONCENTRATION (OTHER FLUIDS),1501945,CDM,300,RC,86335,HCPCS,outpatient,,,119.39,71.63,,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,44.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.83,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,29.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,107.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.78,107.45,
CONCENTRATION INFECTIOUS AGENTS,1502167,CDM,300,RC,87015,HCPCS,outpatient,,,27.59,16.55,,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,24.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.41,24.83,
CONSULTATION,1501963,CDM,300,RC,88321,HCPCS,outpatient,,,142.6,85.56,,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,71.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,128.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,71.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,71.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,128.34,
COPPER (URINE),1500211,CDM,300,RC,82525,HCPCS,outpatient,,,161.18,96.71,,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.13,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,145.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.05,145.06,
"COPPER, (SERUM)",1500482,CDM,300,RC,82525,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.13,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.05,108.18,
COPROPHYRINS,1500339,CDM,300,RC,84120,HCPCS,outpatient,,,124.85,74.91,,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,112.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.92,112.37,
CORDARONE LEVEL,1501377,CDM,300,RC,80299,HCPCS,outpatient,,,138.24,82.94,,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,124.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,124.42,
CORTISOL AM,1500114,CDM,300,RC,82533,HCPCS,outpatient,,,99.16,59.5,,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.19,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,89.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.2,89.24,
CORTISOL FREE - SALIVA,1502322,CDM,300,RC,82530,HCPCS,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.54,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.54,54.34,
CORTISOL PM,1500377,CDM,300,RC,82533,HCPCS,outpatient,,,99.16,59.5,,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.19,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,89.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.2,89.24,
CORTISOL URINE,1501740,CDM,300,RC,82533,HCPCS,outpatient,,,99.16,59.5,,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.19,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,89.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.2,89.24,
COUMADIN LEVEL,1500245,CDM,300,RC,80299,HCPCS,outpatient,,,170.74,102.44,,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,153.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,153.67,
COVID-19 PCR (SARS-CoV-2 RNA) QUEST,1502394,CDM,300,RC,87635,HCPCS,outpatient,,,125.66,75.4,,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,62.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,52.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,113.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,41.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,51.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.56,113.09,
COXSACKIE VIRUS GROUP A,1501390,CDM,300,RC,86658,HCPCS,outpatient,,,171.02,102.61,,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,153.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.56,153.92,
COXSACKIE VIRUS GROUP B,1501302,CDM,300,RC,86658,HCPCS,outpatient,,,279.46,167.68,,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,251.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.56,251.51,
CPK,1500026,CDM,300,RC,82550,HCPCS,outpatient,,,40.17,24.1,,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.46,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,36.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.27,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.27,36.15,
CPK ISOENZYMES,1500097,CDM,300,RC,82552,HCPCS,outpatient,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.46,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,180.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.85,180.96,
Test to measure creatinine in the urine,1500140,CDM,300,RC,82570,HCPCS,outpatient,,,27.81,16.69,,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,25.03,
CREATININE CLEARANCE 24HR URINE,1500028,CDM,300,RC,82575,HCPCS,outpatient,,,174.02,104.41,,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.41,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.41,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.43,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,156.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.66,156.62,
Test to measure creatinine in the urine,1502324,CDM,300,RC,82570,HCPCS,outpatient,,,18.58,11.15,,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,16.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,16.72,
CREATININE OTHER SOURCE,1502488,CDM,300,RC,8257090,HCPCS,outpatient,,,6.18,3.71,,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.27,5.56,
Test to measure creatinine in the urine,1502066,CDM,300,RC,82570,HCPCS,outpatient,,,92.06,55.24,,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,82.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,82.85,
"CREATININE, SERUM",1500027,CDM,300,RC,82565,HCPCS,outpatient,,,108.15,64.89,,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.15,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.15,97.34,
CREUTZFELDT JAKOB DISEASE (PRION),1502331,CDM,300,RC,83520,HCPCS,outpatient,,,91.52,54.91,,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,82.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.99,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.99,82.37,
CROSSMATCH-WASH CELL,1500313,CDM,300,RC,86922,HCPCS,outpatient,,,509.49,305.69,,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,407.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,108.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,458.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,104.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,104.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,104.39,458.54,
CROUP PROFILE,1500380,CDM,300,RC,,,outpatient,,,182.21,109.33,,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.33,163.99,
CRYOGLUBULINS,1500030,CDM,300,RC,82595,HCPCS,outpatient,,,132.77,79.66,,99.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,99.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,119.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,119.49,
CRYPTOCOCCAL ANTIGEN,1501446,CDM,300,RC,86403,HCPCS,outpatient,,,85.79,51.47,,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,77.21,
CRYPTOCOCCUS ANTIBODIES,1501378,CDM,300,RC,86641,HCPCS,outpatient,,,85.79,51.47,,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.67,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.67,77.21,
CRYPTOSPORIDIUM ANTIGEN BY EIA(STOOL),1501815,CDM,300,RC,87328,HCPCS,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.09,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.2,96.63,
CT NG TV HSV (DCH EMPLOYEES ONLY),1501870,CDM,300,RC,87490,HCPCS,outpatient,,,510.3,306.18,,382.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,382.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.13,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,459.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,382.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.43,459.27,
CULTURE ANAEROBIC,1500529,CDM,300,RC,87075,HCPCS,outpatient,,,38.24,22.94,,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,34.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.67,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.67,34.42,
Blood test to screen for bacteria in the blood,1500318,CDM,300,RC,87040,HCPCS,outpatient,,,46.35,27.81,,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.52,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,41.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.36,41.72,
Test of body fluid other than blood to assess for bacteria,1500527,CDM,300,RC,87070,HCPCS,outpatient,,,133.03,79.82,,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,119.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,119.73,
CULTURE CLOSTRIDIUM DIFFICILE(DRL 9990),1500263,CDM,300,RC,87075,HCPCS,outpatient,,,226.47,135.88,,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.46,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,203.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.67,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.67,203.82,
Test of body fluid other than blood to assess for bacteria,1500531,CDM,300,RC,87070,HCPCS,outpatient,,,215.27,129.16,,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,193.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,193.74,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,1500320,CDM,300,RC,87046,HCPCS,outpatient,,,151.41,90.85,,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,136.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,136.27,
Test of body fluid other than blood to assess for bacteria,1500319,CDM,300,RC,87070,HCPCS,outpatient,,,215.27,129.16,,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,193.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,193.74,
Culture of the urine to determine number of bacteria,1500321,CDM,300,RC,87086,HCPCS,outpatient,,,46.35,27.81,,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,41.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.53,41.72,
CULTURE VIRAL,1500435,CDM,300,RC,87250,HCPCS,outpatient,,,131.41,78.85,,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,118.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.84,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.84,118.27,
Test of body fluid other than blood to assess for bacteria,1500322,CDM,300,RC,87070,HCPCS,outpatient,,,215.27,129.16,,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,193.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,193.74,
CYANIDE,1500247,CDM,300,RC,82600,HCPCS,outpatient,,,146.15,87.69,,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.65,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,131.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.71,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.71,131.54,
CYCLIC - AMP,1501959,CDM,300,RC,82030,HCPCS,outpatient,,,251.33,150.8,,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.43,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,26.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.9,226.2,
CYCLOSERINE,1501363,CDM,300,RC,80299,HCPCS,outpatient,,,203.8,122.28,,152.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,152.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,183.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,152.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,183.42,
CYCLOSPORIN,1500463,CDM,300,RC,80158,HCPCS,outpatient,,,142.87,85.72,,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.47,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,128.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.04,128.58,
CYSTATIN C,1502387,CDM,300,RC,82610,HCPCS,outpatient,,,81.96,49.18,,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.08,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,73.76,
CYSTIC FIBROSIS MUTATION PANEL,1501953,CDM,300,RC,81220,HCPCS,outpatient,,,276.74,166.04,,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,723.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1164.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1164.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,567.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,249.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1156.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,450.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1156.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,207.56,1166.4,
CYSTIC FIBROSIS MUTATION SCREEN,1501407,CDM,300,RC,81220,HCPCS,outpatient,,,956.41,573.85,,717.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,765.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,723.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1164.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1164.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,717.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1166.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,567.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,860.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,717.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1156.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,450.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1156.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,556.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,450.85,1166.4,
CYSTICERLOSIS ANTIBODY BY EIA,1501012,CDM,300,RC,86317,HCPCS,outpatient,,,363.67,218.2,,272.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,272.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,327.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,272.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.14,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.14,327.3,
CYSTINE,1500265,CDM,300,RC,82615,HCPCS,outpatient,,,97.25,58.35,,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,87.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.74,87.53,
CYTOGENETICS INTERPRETATION AND REPORT,1501926,CDM,300,RC,88291,HCPCS,outpatient,,,281.39,168.83,,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.07,253.25,
D-DIMER,1501458,CDM,300,RC,85379,HCPCS,outpatient,,,51.5,30.9,,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.24,46.35,
D-XYLOSE 2HR TOLERANCE,1501396,CDM,300,RC,84620,HCPCS,outpatient,,,80.87,48.52,,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.1,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.46,72.78,
D. FARINAE IGE SPEC ALLERGEN (D2),1501216,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
D. PTERONYSSINUS IGE SPEC ALLERGEN (D,1501217,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
DARVON,1500362,CDM,300,RC,80299,HCPCS,outpatient,,,91.52,54.91,,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,82.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,82.37,
DELDTE TERBUTA LINE LEVEL,1500561,CDM,300,RC,82486,HCPCS,outpatient,,,159.03,95.42,,119.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.59,143.13,
DELTA AMINOLEVULINIC ACID,1501345,CDM,300,RC,82135,HCPCS,outpatient,,,252.14,151.28,,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.39,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.33,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.33,226.93,
DENGUE FEVER,1501971,CDM,300,RC,87798,HCPCS,outpatient,,,302.69,181.61,,227.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,227.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,272.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,272.42,
DEOXYCORTISOL-11,1501923,CDM,300,RC,82634,HCPCS,outpatient,,,397.76,238.66,,298.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,44.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,298.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,29.86,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,357.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.72,357.98,
DEPAKENE LEVEL,1500334,CDM,300,RC,80164,HCPCS,outpatient,,,24.72,14.83,,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,22.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.97,22.25,
DESIPRAMINE - SERUM,1501312,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
DESVENLAFAXINE LEVEL,1502384,CDM,300,RC,80338,HCPCS,outpatient,,,184.13,110.48,,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,165.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.73,165.72,
DEXAMETHASONE,1502321,CDM,300,RC,80299,HCPCS,outpatient,,,248.87,149.32,,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,223.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,223.98,
DEXAMETHASONE SUPRESSION,1500550,CDM,300,RC,82533,HCPCS,outpatient,,,294.77,176.86,,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.19,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,265.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.2,265.29,
DFA FOR PERTUSSIS,1501885,CDM,300,RC,87265,HCPCS,outpatient,,,94.79,56.87,,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,85.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,85.31,
DHEA,1500301,CDM,300,RC,82626,HCPCS,outpatient,,,384.1,230.46,,288.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,288.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,25.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,345.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,288.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.47,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,345.69,
Blood test to measure an enzyme in the blood,1500297,CDM,300,RC,82627,HCPCS,outpatient,,,243.68,146.21,,182.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.9,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,182.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,219.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,182.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.01,219.31,
DIAZEPAM LEVEL,1500522,CDM,300,RC,80346,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,315.94,
DIGITOXIN,1500123,CDM,300,RC,80299,HCPCS,outpatient,,,142.06,85.24,,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,127.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,127.85,
DIGOXIN,1500098,CDM,300,RC,80162,HCPCS,outpatient,,,45.32,27.19,,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,40.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.76,40.79,
DIHYDROTESTOSTERONE,1502144,CDM,300,RC,80327,HCPCS,outpatient,,,395.29,237.17,,296.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,296.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,355.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.11,355.76,
DILANTIN LEVEL,1500126,CDM,300,RC,80185,HCPCS,outpatient,,,122.66,73.6,,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,110.39,
DILUTION OF SERUM,1501723,CDM,300,RC,86976,HCPCS,outpatient,,,71.57,42.94,,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.66,64.41,
DIPTHERIA,1501714,CDM,300,RC,86648,HCPCS,outpatient,,,174.56,104.74,,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.24,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,157.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.32,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.32,157.1,
DISOPYTAMINE,1500484,CDM,300,RC,80299,HCPCS,outpatient,,,158.44,95.06,,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,142.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,142.6,
DNA COLLECTION FEE,1502089,CDM,300,RC,,,outpatient,,,42.89,25.73,,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,38.6,
DNA ds ANTIBODY (DOUBLE STRANDED),1501868,CDM,300,RC,86225,HCPCS,outpatient,,,123.75,74.25,,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,111.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.13,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.13,111.38,
DNA PROBE/URINE GC & CHLAMYDIA (Aptima),1501324,CDM,300,RC,87590,HCPCS,outpatient,,,136.87,82.12,,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,27.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,123.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.77,123.18,
DNASE-B ANTIBODY,1501858,CDM,300,RC,86215,HCPCS,outpatient,,,133.31,79.99,,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,119.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,119.98,
DNU DRUG CONFIRMATION GCMS,1501372,CDM,300,RC,80102,HCPCS,outpatient,,,230.29,138.17,,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,115.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.19,207.26,
DNU GAMMA HYDROXYBUTYRIC ACID,1501996,CDM,300,RC,,,outpatient,,,307.05,184.23,,230.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,276.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,193.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.91,276.35,
DOG DANDER IGE SPEC ALLERGEN (E2),1501218,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
DOLOBID LEVEL,1500361,CDM,300,RC,80299,HCPCS,outpatient,,,242.31,145.39,,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,218.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,218.08,
DOXEPIN,1500485,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
DOXYLAMINE LEVEL,1501391,CDM,300,RC,80299,HCPCS,outpatient,,,263.62,158.17,,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,237.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,237.26,
"DRUG MONITOR, MDMA/MDA QUANT UR (39397)",1502485,CDM,300,RC,8035990,HCPCS,outpatient,,,33.48,20.09,,25.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.74,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.86,30.13,
"DRUG MONITOR, SYNTHETIC CANNABINOID QUAN",1502484,CDM,300,RC,8030790,HCPCS,outpatient,,,80.46,48.28,,60.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.23,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.49,72.41,
DRUG MONITORING PANEL 1 (39422),1502444,CDM,300,RC,85306,HCPCS,outpatient,,,15.91,9.55,,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.41,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,14.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.93,23.41,
Testing for presence of drug,1500108,CDM,300,RC,80307,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,80.78,
DRUG SCREEN (HAIR),1501907,CDM,300,RC,80101,HCPCS,outpatient,,,542.54,325.52,,406.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,406.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,488.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,406.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,406.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,271.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.17,488.29,
DRUG SCREEN COLLECTION - INHOUSE DRUG,1502128,CDM,300,RC,,,outpatient,,,55.46,33.28,,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,49.91,
Testing for presence of drug,1502339,CDM,300,RC,80307,HCPCS,outpatient,,,147.79,88.67,,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,133.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,133.01,
Testing for presence of drug,1502053,CDM,300,RC,80307,HCPCS,outpatient,,,81.37,48.82,,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,80.78,
DU TEST,1500461,CDM,300,RC,86901,HCPCS,outpatient,,,69.94,41.96,,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,62.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.42,62.95,
E.COLI/SHIGA TOXIN DETECTION,1501991,CDM,300,RC,87015,HCPCS,outpatient,,,87.69,52.61,,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,78.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.41,78.92,
EASTERN EQUINE ENCEPHALITIS IGG,1502428,CDM,300,RC,8665290,HCPCS,outpatient,,,43.5,26.1,,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,39.15,
EASTERN EQUINE ENCEPHALITIS IGM,1502429,CDM,300,RC,8665290,HCPCS,outpatient,,,43.5,26.1,,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,39.15,
EASTERN EQUINE VIRUS,1501820,CDM,300,RC,86652,HCPCS,outpatient,,,160.63,96.38,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,144.57,
EBV (EPSTEIN BARR VIRUS),1501504,CDM,300,RC,86663,HCPCS,outpatient,,,399.66,239.8,,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,359.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.63,359.69,
EHRLICHIA TITER,1501472,CDM,300,RC,86666,HCPCS,outpatient,,,230.02,138.01,,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,207.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.24,207.02,
EHRLICHIOSIS TITER,1501893,CDM,300,RC,86609,HCPCS,outpatient,,,230.02,138.01,,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,207.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,207.02,
"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",1500033,CDM,300,RC,80051,HCPCS,outpatient,,,298.86,179.32,,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,268.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.68,268.97,
"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",1501853,CDM,300,RC,80051,HCPCS,outpatient,,,298.86,179.32,,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,268.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.68,268.97,
ELM IGE SPEC ALLERGEN (T8),1501219,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
ELUTION,1501720,CDM,300,RC,86860,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,235.29,
ENCEPHALITIS - EASTERN EQUINE,1500405,CDM,300,RC,86652,HCPCS,outpatient,,,235.76,141.46,,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,212.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,212.18,
ENCEPHALITIS - WESTERN EQUINE,1501761,CDM,300,RC,86654,HCPCS,outpatient,,,235.76,141.46,,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,212.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,212.18,
ENCEPHALITIS -ST. LOUIS,1501760,CDM,300,RC,86653,HCPCS,outpatient,,,235.76,141.46,,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,212.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,212.18,
ENCEPHALITIS CALIFORNIA - LACROSSE,1501759,CDM,300,RC,86651,HCPCS,outpatient,,,235.76,141.46,,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,212.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,212.18,
"ENDOMYSIAL ANTIBODY, IGA",1501842,CDM,300,RC,86256,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,217.1,
ENTEROTOXIGENIC ESCHERICHIA,1500559,CDM,300,RC,87335,HCPCS,outpatient,,,60.47,36.28,,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.46,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,12.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.25,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.25,54.42,
ENTEROVIRUS (ARUP 50249),1501754,CDM,300,RC,87498,HCPCS,outpatient,,,79.77,47.86,,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,71.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,71.79,
ENTEROVIRUS BY PCR,1502013,CDM,300,RC,87498,HCPCS,outpatient,,,338.47,203.08,,253.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,253.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,304.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,253.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,304.62,
ENZYMATIC DIGESTION,1501955,CDM,300,RC,83892,HCPCS,outpatient,,,175.66,105.4,,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,158.09,
EOSINOPHIL COUNT,1500125,CDM,300,RC,85048,HCPCS,outpatient,,,86.05,51.63,,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,2.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.06,90,,,fee schedule,90% UHC fee schedule for outpatient setting,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.06,77.45,
"EPST. BARR VIR DNA, QUAL PCR",1502083,CDM,300,RC,87799,HCPCS,outpatient,,,704.53,422.72,,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,150.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,43.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,634.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,144.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,144.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.7,634.08,
Blood test to diagnose mononucleosis,1500330,CDM,300,RC,86665,HCPCS,outpatient,,,399.66,239.8,,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.73,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,359.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.5,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.5,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,359.69,
EPSTEIN-BARR VIRAL CAPSID AB IGG,1502456,CDM,300,RC,8666590,HCPCS,outpatient,,,18.54,11.12,,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.8,16.69,
EPSTEIN-BARR VIRUS NUCLEAR AG AB IGG,1502455,CDM,300,RC,8666490,HCPCS,outpatient,,,16.48,9.89,,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.38,14.83,
ERYTHROCYTE PORPHYRINS,1500444,CDM,300,RC,84202,HCPCS,outpatient,,,58.46,35.08,,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,52.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.63,52.61,
ERYTHROPOIETIN,1500277,CDM,300,RC,82668,HCPCS,outpatient,,,189.05,113.43,,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.71,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,170.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.22,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.22,170.15,
Blood test to measure a type of estrogen in the blood,1501342,CDM,300,RC,82670,HCPCS,outpatient,,,132.5,79.5,,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,42.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.7,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,28.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,119.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.64,90,,,fee schedule,90% UHC fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.64,119.25,
ESTRADIOL FREE,1500357,CDM,300,RC,82681,HCPCS,outpatient,,,123.75,74.25,,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,28.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,111.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.64,90,,,fee schedule,90% UHC fee schedule for outpatient setting,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.64,111.38,
ESTRIOL TOTAL (SERUM OR URINE),1500229,CDM,300,RC,82677,HCPCS,outpatient,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,36.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,180.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.58,180.96,
ESTROGEN RECEPT ASAY,1500391,CDM,300,RC,84233,HCPCS,outpatient,,,426.72,256.03,,320.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,87.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.24,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,98.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,98.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,320.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,89.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,384.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,320.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,97.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,71.18,90,,,fee schedule,90% UHC fee schedule for outpatient setting,87.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,97.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,87.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,71.18,384.05,
ESTROGENS-SERUM,1500122,CDM,300,RC,82672,HCPCS,outpatient,,,459.49,275.69,,344.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,367.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,344.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,413.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,344.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,344.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.58,413.54,
ESTROGENS-URINE,1500149,CDM,300,RC,82672,HCPCS,outpatient,,,207.9,124.74,,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,187.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.58,187.11,
ESTRONE,1502139,CDM,300,RC,82679,HCPCS,outpatient,,,101.62,60.97,,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,25.44,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,91.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.21,91.46,
ETHOSUXIMIDE,1500486,CDM,300,RC,80168,HCPCS,outpatient,,,139.6,83.76,,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.24,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,125.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,125.64,
ETHYLENE GLYCOL,1502002,CDM,300,RC,82693,HCPCS,outpatient,,,89.06,53.44,,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.19,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,80.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.07,80.15,
EXTENDED CASE WORKUP - ARC,1501367,CDM,300,RC,86870,HCPCS,outpatient,,,425.1,255.06,,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,382.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,382.59,
EXTENDED CELL TYPING - RED CROSS,1501310,CDM,300,RC,86905,HCPCS,outpatient,,,70.24,42.14,,52.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.84,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.11,370.6,
EXTRACTION,1501859,CDM,300,RC,83890,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,217.1,
FACTOR II (PROTHROMBIN),1501750,CDM,300,RC,85210,HCPCS,outpatient,,,100.53,60.32,,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.84,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,90.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.68,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.51,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.68,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.51,90.48,
FACTOR IX,1500564,CDM,300,RC,85250,HCPCS,outpatient,,,191.23,114.74,,143.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,143.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,172.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.43,172.11,
FACTOR V,1501452,CDM,300,RC,85220,HCPCS,outpatient,,,180.3,108.18,,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.95,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,162.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.3,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.3,162.27,
FACTOR VII,1501908,CDM,300,RC,85230,HCPCS,outpatient,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.36,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,173.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.5,173.58,
FACTOR VIII,1500563,CDM,300,RC,85240,HCPCS,outpatient,,,199.96,119.98,,149.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,149.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.36,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,179.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.5,179.96,
FACTOR VIII C,1501455,CDM,300,RC,85240,HCPCS,outpatient,,,199.43,119.66,,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.36,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,179.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.5,179.49,
FACTOR VIII OR VON WILLEBRAND ANTIGEN,1502019,CDM,300,RC,85246,HCPCS,outpatient,,,128.67,77.2,,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,115.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.59,115.8,
FACTOR XI,1501290,CDM,300,RC,85270,HCPCS,outpatient,,,202.16,121.3,,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.36,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,181.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.5,181.94,
FACTOR XII,1501288,CDM,300,RC,85280,HCPCS,outpatient,,,208.17,124.9,,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,187.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.68,187.35,
FEBRILE AGGLUTININS,1500034,CDM,300,RC,86000,HCPCS,outpatient,,,163.64,98.18,,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,147.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,147.28,
FECAL CALPROTECTIN,1502000,CDM,300,RC,83993,HCPCS,outpatient,,,382.46,229.48,,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,344.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.9,344.21,
FECAL FAT,1500160,CDM,300,RC,82710,HCPCS,outpatient,,,145.33,87.2,,109,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,109,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.66,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,130.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.61,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.61,130.8,
FELBATOL,1501339,CDM,300,RC,80339,HCPCS,outpatient,,,153.41,92.05,,115.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,115.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.98,138.07,
FELBATOL (FELBAMATE),1501876,CDM,300,RC,80167,HCPCS,outpatient,,,115.01,69.01,,86.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,86.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,103.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,103.51,
FENTANYL SCREEN URINE (39356),1502446,CDM,300,RC,8030790,HCPCS,outpatient,,,54.11,32.47,,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.06,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.09,48.7,
A lab test to screen for evidence of vaginal infection,1501910,CDM,300,RC,87210,HCPCS,outpatient,,,72.4,43.44,,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.72,65.16,
Test to determine level of iron in the blood,1500236,CDM,300,RC,82728,HCPCS,outpatient,,,32.96,19.78,,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.9,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,29.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.04,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.04,29.66,
FETAL LUNG MATURITY,1501463,CDM,300,RC,83661,HCPCS,outpatient,,,89.6,53.76,,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,80.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.81,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.81,80.64,
FETAL SCREEN,1500454,CDM,300,RC,83030,HCPCS,outpatient,,,71.31,42.79,,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.7,64.18,
FIBRIN SPLIT PRODUCT,1500295,CDM,300,RC,85362,HCPCS,outpatient,,,95.61,57.37,,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.58,86.05,
FIBRINOGEN,1500086,CDM,300,RC,85384,HCPCS,outpatient,,,166.64,99.98,,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.95,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.95,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,149.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.88,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.88,149.98,
FIBRO TEST,1502383,CDM,300,RC,81596,HCPCS,outpatient,,,337.65,202.59,,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,93.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,70.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,73.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,303.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,58.47,90,,,fee schedule,90% UHC fee schedule for outpatient setting,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,72.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.47,303.89,
FILTER TYPE PL-100-K,1501728,CDM,300,RC,,,outpatient,,,149.16,89.5,,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,134.24,
FINGERSTICK BLOOD GLUCOSE,2810016,CDM,300,RC,82948,HCPCS,outpatient,,,74.58,44.75,,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.09,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.09,67.12,
FLITER TYPE RCXL1,1501727,CDM,300,RC,,,outpatient,,,39.61,23.77,,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.12,35.65,
FLOW CYTOMETRY (LEUKEMIA/LYMPHOMA PHENOT,1501751,CDM,300,RC,88184,HCPCS,outpatient,,,1842.34,1105.4,,1381.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1473.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1381.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.01,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1658.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1381.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1381.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,1658.11,
Flu test,1501405,CDM,300,RC,87804,HCPCS,outpatient,,,23.69,14.21,,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,21.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.41,21.52,
Flu test,2111287,CDM,300,RC,87804,HCPCS,outpatient,,,80.32,48.19,,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.41,72.29,
Flu test,2112565,CDM,300,RC,87804,HCPCS,outpatient,,,48.89,29.33,,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.41,44,
FLUID FOR CRYSTALS,1500335,CDM,300,RC,89060,HCPCS,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.94,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,97.11,
FOLATE,1500222,CDM,300,RC,82746,HCPCS,outpatient,,,35.02,21.01,,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,31.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.91,31.52,
FOLIC ACID,1501507,CDM,300,RC,82746,HCPCS,outpatient,,,116.1,69.66,,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,104.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.91,104.49,
Test of hormone in the blood,1501497,CDM,300,RC,83001,HCPCS,outpatient,,,125.66,75.4,,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,113.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.05,113.09,
FOOD ALLERGY PANEL,1502086,CDM,300,RC,86003,HCPCS,outpatient,,,521.78,313.07,,391.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,417.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,391.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,469.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,391.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,391.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,469.6,
FORMALDEHYDE,1500309,CDM,300,RC,,,outpatient,,,157.35,94.41,,118.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,118.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,99.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.24,141.62,
FRAGILE X CHROMOSOME ANALYSIS,1501332,CDM,300,RC,81243,HCPCS,outpatient,,,1919.11,1151.47,,1439.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1535.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,424.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,424.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1439.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,58.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1727.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1439.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1439.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1439.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1439.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.73,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,46.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.73,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,57.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,46.21,1727.2,
Blood test to evaluate thyroid function,1502092,CDM,300,RC,84439,HCPCS,outpatient,,,104.63,62.78,,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,94.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.31,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.31,94.17,
FREE CORTISOL (URINE),1501866,CDM,300,RC,82530,HCPCS,outpatient,,,139.87,83.92,,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.54,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,125.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.54,125.88,
FREE ERYTHRO. PORPHY,1500305,CDM,300,RC,84202,HCPCS,outpatient,,,68.3,40.98,,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,61.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.63,61.47,
FREE TESTOSTERONE,1502046,CDM,300,RC,84402,HCPCS,outpatient,,,163.37,98.02,,122.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,122.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,25.97,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,147.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.63,147.03,
FREE TESTOSTERONE,1502051,CDM,300,RC,84402,HCPCS,outpatient,,,198.87,119.32,,149.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,149.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,25.97,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,178.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.63,178.98,
Blood test to evaluate thyroid function,1500296,CDM,300,RC,84439,HCPCS,outpatient,,,142.14,85.28,,106.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,127.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.31,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.31,127.93,
FREIGHT CHARGE,1500542,CDM,300,RC,,,outpatient,,,25.95,15.57,,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,16.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.32,23.36,
FRUCTOSAMINE,1502149,CDM,300,RC,82985,HCPCS,outpatient,,,60.91,36.55,,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.09,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.57,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.57,54.82,
Test of hormone in the blood,1500218,CDM,300,RC,83001,HCPCS,outpatient,,,125.66,75.4,,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.39,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,113.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.05,113.09,
Blood test to determine existence of certain bacterium that causes syphilis,1500121,CDM,300,RC,86780,HCPCS,outpatient,,,156.81,94.09,,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,13.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,141.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.73,141.13,
FTI,1500281,CDM,300,RC,,,outpatient,,,42.34,25.4,,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,38.11,
FUNGAL ANTIBODIES,1502044,CDM,300,RC,86612,HCPCS,outpatient,,,320.99,192.59,,240.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,240.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,288.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,240.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.45,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.45,288.89,
FUNGAL CULTURE,1500210,CDM,300,RC,87102,HCPCS,outpatient,,,127.03,76.22,,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.84,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.57,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,114.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.81,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.81,114.33,
A test used to determine which medications work on bacteria for fungi,1500270,CDM,300,RC,87186,HCPCS,outpatient,,,620.13,372.08,,465.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,465.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.82,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,558.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,465.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,558.12,
FUNGAL STAIN,1501438,CDM,300,RC,87206,HCPCS,outpatient,,,27.59,16.55,,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,24.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.37,24.83,
G6PD,1500143,CDM,300,RC,82955,HCPCS,outpatient,,,175.92,105.55,,131.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,131.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,158.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.86,158.33,
GABAPENTIN,1501400,CDM,300,RC,80171,HCPCS,outpatient,,,210.36,126.22,,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.17,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,189.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.55,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,189.32,
"GALACTOSE ALPHA 1,3, GALACTOSE IGE (9524",1502448,CDM,300,RC,8600890,HCPCS,outpatient,,,53.05,31.83,,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,47.75,
Test to determine levels of immunoglobulins in the blood,1501865,CDM,300,RC,82784,HCPCS,outpatient,,,80.32,48.19,,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,72.29,
GANGLIONIC nAChR ANTIBODY TEST,1502138,CDM,300,RC,83519,HCPCS,outpatient,,,1131.53,678.92,,848.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,905.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,848.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1018.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,848.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,1018.38,
GASTRIC ANALYSIS TB,1500035,CDM,300,RC,87118,HCPCS,outpatient,,,167.19,100.31,,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,14.9,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,150.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.84,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.84,150.47,
GASTRIC ANALYSIS TBL,1500036,CDM,300,RC,82930,HCPCS,outpatient,,,62.28,37.37,,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,56.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.44,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.44,56.05,
GASTRIC OCCULT BLOOD,1502078,CDM,300,RC,82271,HCPCS,outpatient,,,32.51,19.51,,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,29.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.31,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.31,29.26,
GASTRIC PARIATAL CELL AB,1502297,CDM,300,RC,86255,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,26.8,
GASTRIC PH,1502082,CDM,300,RC,83986,HCPCS,outpatient,,,27.59,16.55,,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,24.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.9,24.83,
GASTRIN,1500173,CDM,300,RC,82941,HCPCS,outpatient,,,290.67,174.4,,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,261.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.28,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.28,261.6,
Blood test for an STD,1501872,CDM,300,RC,87591,HCPCS,outpatient,,,79.23,47.54,,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,71.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,71.31,
GEL SEPARATION,1501831,CDM,300,RC,81244,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,119.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.56,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,45.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,36.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.36,217.1,
GENTAMICIN PEAK,1500120,CDM,300,RC,80170,HCPCS,outpatient,,,94.26,56.56,,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.27,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.27,84.83,
GENTAMICIN TROUGH,1501120,CDM,300,RC,80170,HCPCS,outpatient,,,93.98,56.39,,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.27,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.27,84.58,
GGT,1500241,CDM,300,RC,82977,HCPCS,outpatient,,,100.53,60.32,,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.34,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,90.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.83,90.48,
GIARDIA SPECIFIC ANTIGEN(STOOL),1501423,CDM,300,RC,87329,HCPCS,outpatient,,,68.57,41.14,,51.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,61.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,61.71,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1501845,CDM,300,RC,83516,HCPCS,outpatient,,,328.1,196.86,,246.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,246.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,295.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,246.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,295.29,
GLOBULIN,1500037,CDM,300,RC,86880,HCPCS,outpatient,,,19.63,11.78,,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,17.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.37,65.72,
"GLOMERULAR FILTRATION RATE, PEDIATRIC",1502068,CDM,300,RC,82565,HCPCS,outpatient,,,30.87,18.52,,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,27.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.15,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.15,27.78,
Quantitative measure of glucose build up in the blood over time,1500038,CDM,300,RC,82947,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.19,106.47,
GLUCOSE CSF,1500524,CDM,300,RC,82945,HCPCS,outpatient,,,83.33,50,,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.19,75,
GLUCOSE PLEURAL FLUID (17425),1502493,CDM,300,RC,8294590,HCPCS,outpatient,,,4.44,2.66,,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.91,4,
Test to predict likelihood of gestational diabetes,1501522,CDM,300,RC,82951,HCPCS,outpatient,,,306.24,183.74,,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,275.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,275.62,
Test to predict likelihood of gestational diabetes,1501480,CDM,300,RC,82951,HCPCS,outpatient,,,306.24,183.74,,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,275.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,275.62,
GLUTAMIC ACID DECARBOXYLASE ANTIBODY,1501862,CDM,300,RC,86341,HCPCS,outpatient,,,275.37,165.22,,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.24,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,247.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,206.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.09,90,,,fee schedule,90% UHC fee schedule for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.09,247.83,
GONADOTROPIN RELEASING HORMONE,1502101,CDM,300,RC,83727,HCPCS,outpatient,,,548.01,328.81,,411.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.35,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,411.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,493.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,411.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,411.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.92,493.21,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,1500040,CDM,300,RC,87205,HCPCS,outpatient,,,73.49,44.09,,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,66.14,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,1500041,CDM,300,RC,87205,HCPCS,outpatient,,,18.54,11.12,,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,16.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,16.69,
GROUP A COXSACKIE VIRAL PANEL,1501321,CDM,300,RC,86658,HCPCS,outpatient,,,148.1,88.86,,111.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,111.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,133.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.56,133.29,
GROUP B COXSACKIE VIRAL PANAL,1500556,CDM,300,RC,86658,HCPCS,outpatient,,,282.3,169.38,,211.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,211.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,254.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,211.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.56,254.07,
"GROWTH HORMONE, HUMA",1500303,CDM,300,RC,83003,HCPCS,outpatient,,,163.64,98.18,,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,147.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.5,147.28,
H BE AG,1500327,CDM,300,RC,87350,HCPCS,outpatient,,,72.68,43.61,,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,65.41,
H INFLUENZAE ANTIGEN,1500406,CDM,300,RC,87400,HCPCS,outpatient,,,109.55,65.73,,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.45,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.45,98.6,
Test of breath for a stomach bacterium,1502123,CDM,300,RC,83013,HCPCS,outpatient,,,461.13,276.68,,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,67.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,80.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.83,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,68.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,415.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,54.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,67.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,67.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.56,415.02,
H. INFLUENZA TYPE B AB (IGG) (35135),1502450,CDM,300,RC,8668490,HCPCS,outpatient,,,53.05,31.83,,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.87,47.75,
H. PYLORI STAT UREASE,1501308,CDM,300,RC,82657,HCPCS,outpatient,,,37.08,22.25,,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,33.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.96,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,33.37,
H. PYLORIC ANTIGEN (STOOL),1501965,CDM,300,RC,87338,HCPCS,outpatient,,,78.28,46.97,,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.65,70.45,
HAAB IGM,1500331,CDM,300,RC,86709,HCPCS,outpatient,,,124.57,74.74,,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,112.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.12,112.11,
HALCION-TRIAZDAM,1500457,CDM,300,RC,80346,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,315.94,
HALOPERIDOL,1500487,CDM,300,RC,80173,HCPCS,outpatient,,,184.95,110.97,,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.09,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,166.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.78,166.46,
HAPTOGLOBIN,1500119,CDM,300,RC,83010,HCPCS,outpatient,,,90.42,54.25,,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.35,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.83,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,81.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,81.38,
HBSAG,1500358,CDM,300,RC,87340,HCPCS,outpatient,,,125.39,75.23,,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,112.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.37,112.85,
HCG QUANTITATIVE,1500165,CDM,300,RC,84702,HCPCS,outpatient,,,57.68,34.61,,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,51.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,51.91,
HCT,1500151,CDM,300,RC,85014,HCPCS,outpatient,,,9.27,5.56,,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.08,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,2.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,8.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,1.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.92,8.34,
Blood test to measure the level of lipoproteins in the blood,1500488,CDM,300,RC,83718,HCPCS,outpatient,,,57.92,34.75,,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,52.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.63,52.13,
HE4 OVARIAN CANCER MONITORING (16500),1502479,CDM,300,RC,8630590,HCPCS,outpatient,,,193.64,116.18,,145.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,145.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.82,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.68,174.28,
HEALTH FAIR OCCULT BLOOD,1502085,CDM,300,RC,82272,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,4.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.43,5.5,
"Blood test, lipids (cholesterol and triglycerides)",1501974,CDM,300,RC,80061,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,20.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.85,20.47,
HEAVY METAL SCREEN (BLOOD),1500166,CDM,300,RC,83015,HCPCS,outpatient,,,160.63,96.38,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.72,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.72,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.97,144.57,
Blood test to if peptic ulcers are caused by a certain bacterium,1501517,CDM,300,RC,86677,HCPCS,outpatient,,,94.26,56.56,,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.65,84.83,
HEMACHROMATOSIS,1501805,CDM,300,RC,81256,HCPCS,outpatient,,,1258.55,755.13,,943.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1006.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,84.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,943.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,66.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1132.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,943.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,52.94,90,,,fee schedule,90% UHC fee schedule for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,1132.7,
HEMOCHROMATOSIS MUTATION DETECTION(HFE),1502018,CDM,300,RC,81256,HCPCS,outpatient,,,473.43,284.06,,355.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,84.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,355.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,66.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,426.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,355.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,52.94,90,,,fee schedule,90% UHC fee schedule for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,426.09,
HEMOCULT,2500072,CDM,300,RC,82272,HCPCS,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.43,6.49,
Blood test to measure average blood glucose levels for past 2-3 months,1500539,CDM,300,RC,83036,HCPCS,outpatient,,,35.02,21.01,,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.8,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.82,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.9,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,31.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.87,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.87,31.52,
HEMOGLOBIN ELECTROPH,1500099,CDM,300,RC,83021,HCPCS,outpatient,,,199.43,119.66,,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,179.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,179.49,
HEMOGLOBINOPATHY PROFILE,1501385,CDM,300,RC,83020,HCPCS,outpatient,,,131.45,78.87,,98.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,98.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,118.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,118.31,
HEMOSIDERIN,1501453,CDM,300,RC,83070,HCPCS,outpatient,,,24.32,14.59,,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,21.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.85,21.89,
HEP C RNA (QUAL) BY TMA,1501873,CDM,300,RC,87522,HCPCS,outpatient,,,949.3,569.58,,711.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65.34,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,65.34,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,711.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.45,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,43.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,854.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,711.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.91,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,34.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.91,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.7,854.37,
HEP. A IGM,1500359,CDM,300,RC,86709,HCPCS,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.12,92.44,
HEPARIN INDUCED PLATELET AB,1502008,CDM,300,RC,86022,HCPCS,outpatient,,,344.76,206.86,,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,310.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.88,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.88,310.28,
Blood test indicating infection with Hepatitis A,1500342,CDM,300,RC,86708,HCPCS,outpatient,,,21.63,12.98,,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,19.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.04,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.04,19.47,
HEPATITIS B CORE AB IGM (4848),1502463,CDM,300,RC,8670590,HCPCS,outpatient,,,7.57,4.54,,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.55,6.81,
Blood test indicating infection with Hepatitis B,1501846,CDM,300,RC,86704,HCPCS,outpatient,,,17.51,10.51,,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,15.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,18.42,
HEPATITIS B SURFACE ANTIBODY,1500341,CDM,300,RC,86317,HCPCS,outpatient,,,22.66,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,20.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.14,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.14,20.39,
HEPATITIS B SURFACE ANTIGEN,1500101,CDM,300,RC,87340,HCPCS,outpatient,,,50.82,30.49,,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.37,45.74,
HEPATITIS B VIRAL LOADD,1501465,CDM,300,RC,86706,HCPCS,outpatient,,,342.84,205.7,,257.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,257.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,308.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,257.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.7,308.56,
HEPATITIS B VIRUS AB DNA QUANT PCR (836,1502453,CDM,300,RC,8751790,HCPCS,outpatient,,,90.64,54.38,,67.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.32,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.57,81.58,
HEPATITIS BE AB (556),1502454,CDM,300,RC,8670790,HCPCS,outpatient,,,8.24,4.94,,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,7.42,
HEPATITIS BE ANTIGEN,1501930,CDM,300,RC,87350,HCPCS,outpatient,,,101.35,60.81,,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,91.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,91.22,
Blood test to determine infection with Hepatitis C,1500535,CDM,300,RC,86803,HCPCS,outpatient,,,25.75,15.45,,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.55,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.56,23.18,
HEPATITIS C GENOTYPE,1501897,CDM,300,RC,87902,HCPCS,outpatient,,,742.77,445.66,,557.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,594.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,334.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,133.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,557.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,262.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,668.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,557.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,557.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,557.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,557.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,208.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,668.49,
HEPATITIS C VIRAL LOAD,1501456,CDM,300,RC,87522,HCPCS,outpatient,,,650.72,390.43,,488.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,520.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65.34,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,65.34,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,488.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.45,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,43.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,585.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,488.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.91,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,34.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.91,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,42.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.7,585.65,
HEPATITIS C VIRAL RNA QUALITATIVE TMA,1502155,CDM,300,RC,87521,HCPCS,outpatient,,,537.35,322.41,,403.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,403.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,483.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,403.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,403.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,403.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,403.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,483.62,
HER-2/neu (FISH),1501752,CDM,300,RC,88365,HCPCS,outpatient,,,361.69,217.01,,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,106.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,325.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,325.52,
HERPES SIMP ANTI CF,1500410,CDM,300,RC,86171,HCPCS,outpatient,,,102.18,61.31,,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,91.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.11,91.96,
HERPES SIMPLEX DFA,1501445,CDM,300,RC,87207,HCPCS,outpatient,,,118.02,70.81,,88.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,88.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.85,106.22,
HERPES SIMPLEX IGG AB I&II,1501992,CDM,300,RC,86695,HCPCS,outpatient,,,81.96,49.18,,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,73.76,
HERPES SIMPLEX IGM AB I&II,1501993,CDM,300,RC,86694,HCPCS,outpatient,,,60.38,36.23,,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,54.34,
HERPES SIMPLEX VIRUS,1501442,CDM,300,RC,86695,HCPCS,outpatient,,,247.51,148.51,,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,222.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,222.76,
HERPES SIMPLEX VIRUS I AND II,1501459,CDM,300,RC,86694,HCPCS,outpatient,,,58.77,35.26,,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,52.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,52.89,
HETEROPHILE,1500286,CDM,300,RC,86308,HCPCS,outpatient,,,82.77,49.66,,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,74.49,
Blood test to measure levels of hemoglobin,1500043,CDM,300,RC,85018,HCPCS,outpatient,,,9.27,5.56,,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.08,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,2.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,8.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,1.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.92,8.34,
Blood test to measure the level of lipoproteins in the blood,1500397,CDM,300,RC,83718,HCPCS,outpatient,,,93.43,56.06,,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.63,84.09,
HISTAMINE PLASMA,1502061,CDM,300,RC,83088,HCPCS,outpatient,,,361.97,217.18,,271.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.39,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,45.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,271.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,325.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,271.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,325.77,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1501964,CDM,300,RC,83516,HCPCS,outpatient,,,158.44,95.06,,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,142.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,142.6,
HISTOPLASMA ANTIBODIES,1501381,CDM,300,RC,86698,HCPCS,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.06,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.17,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.17,72.04,
"HISTOPLASMA GALACTOMANNAN AG, UR, (912",1502451,CDM,300,RC,8738590,HCPCS,outpatient,,,58.35,35.01,,43.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.96,52.52,
HISTOPLASMOSIS,1500475,CDM,300,RC,87385,HCPCS,outpatient,,,129.76,77.86,,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,116.78,
Blood test to diagnose HIV,1500436,CDM,300,RC,86703,HCPCS,outpatient,,,188.49,113.09,,141.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,141.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.18,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,169.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.11,169.64,
HIV 1 QUANTIFICATION - VIRAL LOAD,1501457,CDM,300,RC,87536,HCPCS,outpatient,,,381.36,228.82,,286.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,305.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,110.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,68.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,286.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.65,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,86.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,343.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,286.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,68.93,90,,,fee schedule,90% UHC fee schedule for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.08,343.22,
HIV ANTIBODY 1/2 DIFFERENTIATION,1501975,CDM,300,RC,87535,HCPCS,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,72.04,
Test for HIV,1501898,CDM,300,RC,87389,HCPCS,outpatient,,,256.51,153.91,,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,230.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.5,230.86,
HIV GENOTYPE,1501418,CDM,300,RC,87901,HCPCS,outpatient,,,599.19,359.51,,449.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,334.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,133.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,449.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,262.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,539.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,449.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,208.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,539.27,
HIV GENOTYPE,1501757,CDM,300,RC,87901,HCPCS,outpatient,,,1224.95,734.97,,918.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,334.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,133.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,918.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,262.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1102.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,918.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,918.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,208.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,257.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.14,1102.46,
HIV I RNA BY BRANCH DNA,1501427,CDM,300,RC,87536,HCPCS,outpatient,,,482.93,289.76,,362.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,386.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,110.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,68.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,362.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.65,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,86.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,434.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,362.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,68.93,90,,,fee schedule,90% UHC fee schedule for outpatient setting,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,85.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.08,434.64,
HIV PHENOTYPE,1501521,CDM,300,RC,87903,HCPCS,outpatient,,,1527.09,916.25,,1145.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1221.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,488.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,635.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,515.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,515.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1145.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,516.74,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,498.43,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1374.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1145.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1145.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1145.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1145.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,488.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,488.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,512.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,395.81,90,,,fee schedule,90% UHC fee schedule for outpatient setting,488.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,512.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,488.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,395.81,1374.38,
HIV WITH P24 ANTIGEN TITER,1501303,CDM,300,RC,87390,HCPCS,outpatient,,,492.82,295.69,,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,443.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.49,90,,,fee schedule,90% UHC fee schedule for outpatient setting,24.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,443.54,
HIV-1 RNA BY PCR,1501948,CDM,300,RC,87535,HCPCS,outpatient,,,501.29,300.77,,375.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,375.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,451.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,375.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,375.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,451.16,
HLA B,1502021,CDM,300,RC,81381,HCPCS,outpatient,,,384.37,230.62,,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,220.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,173.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,345.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,137.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,169.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,345.93,
HLA D4,1501338,CDM,300,RC,86816,HCPCS,outpatient,,,902.59,541.55,,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,42.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.56,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,812.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.44,90,,,fee schedule,90% UHC fee schedule for outpatient setting,30.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,30.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.44,812.33,
HLA TYPING (A AND B LOCI),1501305,CDM,300,RC,86813,HCPCS,outpatient,,,1251.73,751.04,,938.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1001.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,75.4,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.45,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,88.45,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,938.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,59.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1126.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,938.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,938.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,938.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,938.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,46.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,46.98,1126.56,
HLAB27,1500115,CDM,300,RC,86812,HCPCS,outpatient,,,337.65,202.59,,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.43,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,26.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,303.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.91,303.89,
HOMOCYSTINE,1501350,CDM,300,RC,83090,HCPCS,outpatient,,,225.11,135.07,,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,202.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.52,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.52,202.6,
HOMOVANILLIC ACID,1500283,CDM,300,RC,83150,HCPCS,outpatient,,,154.62,92.77,,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.13,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.15,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.15,139.16,
HOSP OPT CLNC SPEC COL COVID19,1502436,CDM,300,RC,C9803,HCPCS,outpatient,,,26.52,15.91,,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.43,28.54,
HSV 1 & 2 PCR - CSF,1501441,CDM,300,RC,87529,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,315.94,
HSV Type 1 and 2 PCR Genital,1502309,CDM,300,RC,87529,HCPCS,outpatient,,,77.58,46.55,,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,69.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,69.82,
HUMAN GROWTH HORMONE,1501817,CDM,300,RC,83003,HCPCS,outpatient,,,107.64,64.58,,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,96.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.5,96.88,
HUMAN PAPILLOMAVIRUS HIGH RISK,1502423,CDM,300,RC,8762490,HCPCS,outpatient,,,42.44,25.46,,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,38.2,
HUNTINGTON DISEASE,1501860,CDM,300,RC,81271,HCPCS,outpatient,,,964.61,578.77,,723.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,771.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,178.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,132.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,132.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,723.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,139.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,868.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,723.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,723.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,110.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,110.97,868.15,
Testing for presence of drug,1501770,CDM,300,RC,80307,HCPCS,outpatient,,,160.63,96.38,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,144.57,
Testing for presence of drug,1500474,CDM,300,RC,80307,HCPCS,outpatient,,,82.33,49.4,,61.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,61.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,80.78,
HYDROXYLASE ANTIBODY (39226),1502478,CDM,300,RC,8351690,HCPCS,outpatient,,,115.36,69.22,,86.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.68,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.64,103.82,
"HYDROXYPROLINE, TOTAL URINE",1502010,CDM,300,RC,83505,HCPCS,outpatient,,,99.16,59.5,,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,37.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.13,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,89.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,24.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.68,89.24,
HYDROXYZINE METABOLITE URINE/BLOOD,1502127,CDM,300,RC,80299,HCPCS,outpatient,,,278.1,166.86,,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,250.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,250.29,
HYPOGLYCEMIC PANEL,1502473,CDM,300,RC,8037790,HCPCS,outpatient,,,462.47,277.48,,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,416.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,346.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.76,416.22,
IA-2 ANTIBODY (37933),1502491,CDM,300,RC,8634190,HCPCS,outpatient,,,123.6,74.16,,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.33,111.24,
IBD PANEL - INFLAMMATORY BOWEL DISEASE D,1502034,CDM,300,RC,86255,HCPCS,outpatient,,,476.43,285.86,,357.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,357.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,428.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,357.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,357.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,428.79,
Test to determine levels of immunoglobulins in the blood,1500204,CDM,300,RC,82784,HCPCS,outpatient,,,122.66,73.6,,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,110.39,
Test to determine levels of immunoglobulins in the blood,1500205,CDM,300,RC,82784,HCPCS,outpatient,,,154.62,92.77,,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,139.16,
IGE,1500179,CDM,300,RC,82785,HCPCS,outpatient,,,153.25,91.95,,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.4,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,137.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.33,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.33,137.93,
IGF - I,1501855,CDM,300,RC,84305,HCPCS,outpatient,,,308.7,185.22,,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.68,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,277.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.22,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.22,277.83,
IGF PROTEIN 3,1501731,CDM,300,RC,83519,HCPCS,outpatient,,,150.79,90.47,,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,135.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,135.71,
Test to determine levels of immunoglobulins in the blood,1500206,CDM,300,RC,82784,HCPCS,outpatient,,,128.67,77.2,,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,115.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,115.8,
IGG SUBCLASSES,1501349,CDM,300,RC,82787,HCPCS,outpatient,,,268,160.8,,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,241.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.5,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.5,241.2,
Test to determine levels of immunoglobulins in the blood,1501443,CDM,300,RC,82784,HCPCS,outpatient,,,92.06,55.24,,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,82.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,82.85,
Test to determine levels of immunoglobulins in the blood,1500207,CDM,300,RC,82784,HCPCS,outpatient,,,122.66,73.6,,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,110.39,
Test to determine levels of immunoglobulins in the blood,1500490,CDM,300,RC,82784,HCPCS,outpatient,,,115.83,69.5,,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,104.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,104.25,
IMIPRIMINE,1500491,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
IMMUNE COMPLEX PANEL,1500317,CDM,300,RC,86332,HCPCS,outpatient,,,277.28,166.37,,207.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,37.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,207.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.24,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,249.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,207.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.74,249.55,
Test to determine levels of immunoglobulins in the blood,1501351,CDM,300,RC,82784,HCPCS,outpatient,,,1082.08,649.25,,811.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,811.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,973.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,811.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,973.87,
IMMUNO,1501863,CDM,300,RC,86334,HCPCS,outpatient,,,185.76,111.46,,139.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,139.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.1,167.18,
IMMUNO DEFICIENCY PANEL VIII,1501354,CDM,300,RC,,,outpatient,,,948.21,568.93,,711.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,201.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,201.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,711.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,853.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,711.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,597.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.29,853.39,
IMMUNOFIXATION / SERUM,1501298,CDM,300,RC,86334,HCPCS,outpatient,,,423.17,253.9,,317.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,317.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.13,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,380.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.1,380.85,
IMMUNOFIXATION CSF,1502368,CDM,300,RC,86335,HCPCS,outpatient,,,39.34,23.6,,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,44.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.83,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,29.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.78,44.83,
IMMUNOFIXATION ELECTROPHORISIS,1502415,CDM,300,RC,86335,HCPCS,outpatient,,,79.77,47.86,,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,44.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.83,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,29.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,71.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.78,71.79,
IMMUNOFIXATION URINE,1501329,CDM,300,RC,86325,HCPCS,outpatient,,,190.14,114.08,,142.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,142.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,171.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,142.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.74,171.13,
IMMUNOGLOBULIN IGE,1501230,CDM,300,RC,8278590,HCPCS,outpatient,,,52.18,31.31,,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,46.96,
Test to determine levels of immunoglobulins in the blood,1500102,CDM,300,RC,82784,HCPCS,outpatient,,,302.96,181.78,,227.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,227.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,272.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.53,272.66,
Pathology test,1501471,CDM,300,RC,88342,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,86.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,86.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.25,417.97,
INCUBATED-AGGLUTINATION,1501726,CDM,300,RC,86941,HCPCS,outpatient,,,69.66,41.8,,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,62.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.81,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,62.69,
A lab test to screen for evidence of vaginal infection,1500045,CDM,300,RC,87210,HCPCS,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.72,57.78,
A lab test to screen for evidence of vaginal infection,1501376,CDM,300,RC,87210,HCPCS,outpatient,,,72.4,43.44,,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.72,65.16,
INDIRECT TITER,1501722,CDM,300,RC,86886,HCPCS,outpatient,,,95.88,57.53,,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,179.8,
INF AGT ID RNA TRICHOMONAS VAGIN (19550),1502447,CDM,300,RC,8766190,HCPCS,outpatient,,,100.79,60.47,,75.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.4,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.65,90.71,
INFLIXIMAB FOR RHEUMMATIC DISEASES,1502457,CDM,300,RC,8023090,HCPCS,outpatient,,,128.75,77.25,,96.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.38,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.38,115.88,
INFLUENZA A VIRUS,1500390,CDM,300,RC,87276,HCPCS,outpatient,,,71.03,42.62,,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.89,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,63.93,
INFLUENZA B VIRUS,1500555,CDM,300,RC,87275,HCPCS,outpatient,,,71.03,42.62,,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.93,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.93,63.93,
Blood test to monitor for cancer in the ovaries or testis,1501901,CDM,300,RC,86336,HCPCS,outpatient,,,121.29,72.77,,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.9,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,109.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.63,109.16,
INHIBIN B (34445),1502490,CDM,300,RC,8352090,HCPCS,outpatient,,,93.73,56.24,,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.21,84.36,
INHIBITION OF SERUM,1501724,CDM,300,RC,86977,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,235.29,
INSULIN AUTOANTIBODY (36178),1502494,CDM,300,RC,8633790,HCPCS,outpatient,,,71.07,42.64,,53.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.54,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.56,63.96,
INSULIN FREE,1502148,CDM,300,RC,83527,HCPCS,outpatient,,,52.45,31.47,,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,47.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.49,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.49,47.21,
INSULIN LEVEL,1500215,CDM,300,RC,83525,HCPCS,outpatient,,,146.42,87.85,,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,131.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.26,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.26,131.78,
INTERFERON BETA 1a AB,1502109,CDM,300,RC,,,outpatient,,,705.09,423.05,,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,444.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,634.58,
INTERFERON BETA 1b AB,1502107,CDM,300,RC,,,outpatient,,,705.09,423.05,,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,444.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,634.58,
INTERLEUKIN 6,1501969,CDM,300,RC,82397,HCPCS,outpatient,,,358.14,214.88,,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,322.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,268.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.44,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.44,322.33,
INTERPRETATION AND REPORT,1501832,CDM,300,RC,83912,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,217.1,
INTRINSIC FACTOR BLOCKING ANTIBODY,1501451,CDM,300,RC,86340,HCPCS,outpatient,,,154.89,92.93,,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.21,139.4,
IODINE,1500368,CDM,300,RC,83789,HCPCS,outpatient,,,142.33,85.4,,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,128.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,24.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,128.1,
Blood test to measure the amount of iron that is in transit in the body,1500047,CDM,300,RC,83540,HCPCS,outpatient,,,36.05,21.63,,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,32.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,32.45,
Blood test that measures the amount of iron carried in the blood,1500152,CDM,300,RC,83550,HCPCS,outpatient,,,63.13,37.88,,47.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.33,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.33,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,47.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,56.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.08,56.82,
Blood test to measure the amount of iron that is in transit in the body,1502004,CDM,300,RC,83540,HCPCS,outpatient,,,273.19,163.91,,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,245.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,245.87,
ISLET CELL ANTIBODY,1501413,CDM,300,RC,86341,HCPCS,outpatient,,,123.2,73.92,,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.24,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.09,90,,,fee schedule,90% UHC fee schedule for outpatient setting,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.09,110.88,
ISOLATION,1501828,CDM,300,RC,83891,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,120.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,217.1,
ISOPROPYL ALCOHOL LEVEL,1501301,CDM,300,RC,80320,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,315.94,
IVEY BLEEDING TIME,1500157,CDM,300,RC,85002,HCPCS,outpatient,,,75.4,45.24,,56.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,56.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.91,67.86,
JVA ANTIBODY W/INDEX,1502466,CDM,300,RC,8671190,HCPCS,outpatient,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
KAPPA LIGHT CHAINS,1502105,CDM,300,RC,83883,HCPCS,outpatient,,,135.5,81.3,,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.02,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.02,121.95,
KAPPA/LAMBDA LIGHT CHAINS,1501745,CDM,300,RC,83883,HCPCS,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.02,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.02,49.42,
KEPPRA (LEVETIRACETAM),1501849,CDM,300,RC,80177,HCPCS,outpatient,,,492.82,295.69,,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,394.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,443.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,443.54,
KETONE (SERUM),1500292,CDM,300,RC,82009,HCPCS,outpatient,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,24.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.66,24.1,
KETONE (SERUM),1500453,CDM,300,RC,82009,HCPCS,outpatient,,,38.24,22.94,,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,34.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.66,34.42,
Manual urinalysis test with examination using microscope,1502087,CDM,300,RC,81000,HCPCS,outpatient,,,88.24,52.94,,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,79.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.26,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.26,79.42,
KLEIHAUER-BETKE OBSOLETE TEST,1501856,CDM,300,RC,85460,HCPCS,outpatient,,,196.69,118.01,,147.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,147.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,177.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,147.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.26,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.66,177.02,
LAB ONE ADDITIONAL DRAW,1501707,CDM,300,RC,,,outpatient,,,3.28,1.97,,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,2.95,
LAB ONE COLLECTION FEE,1501706,CDM,300,RC,,,outpatient,,,19.13,11.48,,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,17.22,
LAB ONE DROP-OFF CHARGE,1501708,CDM,300,RC,,,outpatient,,,9.56,5.74,,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
LACTIC ACID,1500231,CDM,300,RC,83605,HCPCS,outpatient,,,61.8,37.08,,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,55.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.37,55.62,
LACTIC ACID CSF,1502333,CDM,300,RC,83605,HCPCS,outpatient,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,12.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.37,16.32,
"LACTOFERRIN, STOOL",1502122,CDM,300,RC,83630,HCPCS,outpatient,,,215.27,129.16,,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.09,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,193.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.96,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.96,193.74,
Test to predict likelihood of gestational diabetes,1502088,CDM,300,RC,82951,HCPCS,outpatient,,,130.58,78.35,,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,117.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,117.52,
LAMBDA LIGHT CHAINS,1501746,CDM,300,RC,83883,HCPCS,outpatient,,,136.59,81.95,,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,122.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.02,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.02,122.93,
LAMELLAR BODY COUNT,1502147,CDM,300,RC,,,outpatient,,,51.36,30.82,,38.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.52,46.22,
LAMOTRIGINE,1501851,CDM,300,RC,80175,HCPCS,outpatient,,,47.8,28.68,,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,43.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,43.02,
LANOXIN TOTAL,1501485,CDM,300,RC,80162,HCPCS,outpatient,,,89.6,53.76,,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,80.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.76,80.64,
LATEX SPECIFIC IqE PANEL,1502112,CDM,300,RC,86003,HCPCS,outpatient,,,377.55,226.53,,283.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,283.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,339.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,283.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,339.8,
LDH,1500050,CDM,300,RC,83615,HCPCS,outpatient,,,79.31,47.59,,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,71.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.9,71.38,
LDH (FRACTIONATED),1500146,CDM,300,RC,83625,HCPCS,outpatient,,,171.02,102.61,,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,153.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.79,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,153.92,
LDH CSF,1502332,CDM,300,RC,83615,HCPCS,outpatient,,,45.35,27.21,,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,40.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.9,40.82,
LDH PLEURAL FLUID,1501854,CDM,300,RC,83615,HCPCS,outpatient,,,156.26,93.76,,117.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,117.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,140.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.9,140.63,
LDL DIRECT,1501918,CDM,300,RC,83721,HCPCS,outpatient,,,109.83,65.9,,82.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,82.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.51,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.51,98.85,
LEAD & PROTOPORPHRIN RBC,1501036,CDM,300,RC,84202,HCPCS,outpatient,,,114.46,68.68,,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,103.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.63,103.01,
Blood test to determine the concentration of lead in the blood,1500224,CDM,300,RC,83655,HCPCS,outpatient,,,86.05,51.63,,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.81,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,77.45,
LECITHIN SPHINGOMYELIN RATIO,1501503,CDM,300,RC,83661,HCPCS,outpatient,,,177.03,106.22,,132.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,132.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,159.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.81,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.81,159.33,
LEFLUNOMIDE LEVEL,1502097,CDM,300,RC,80193,HCPCS,outpatient,,,278.1,166.86,,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,37.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,39.34,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,250.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,31.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,38.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.24,250.29,
LEGIONELLA ANTIBODIES,1501341,CDM,300,RC,86713,HCPCS,outpatient,,,228.1,136.86,,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.89,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.39,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,205.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.39,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,205.29,
LEGIONELLA PCR,1500445,CDM,300,RC,87541,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,417.97,
LEPTOSPIRA,1500312,CDM,300,RC,86720,HCPCS,outpatient,,,121.57,72.94,,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.52,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,109.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.12,109.41,
LEPTOSPIRAL ANTIBODIES,1501382,CDM,300,RC,86720,HCPCS,outpatient,,,57.5,34.5,,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.52,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,51.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.12,51.75,
LEUCINE AMNIOPEPTIDASE,1500254,CDM,300,RC,83670,HCPCS,outpatient,,,134.13,80.48,,100.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,100.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.95,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.95,120.72,
LEUKOCYTE ALK PHOS STAIN,1500558,CDM,300,RC,85540,HCPCS,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.97,97.11,
LEUKOCYTE ALKALINE PH,1500252,CDM,300,RC,85540,HCPCS,outpatient,,,158.17,94.9,,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,142.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.97,142.35,
LEUKOCYTE ALKALINE PHOSPHATASE,1501432,CDM,300,RC,85540,HCPCS,outpatient,,,268.53,161.12,,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,241.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.97,241.68,
Test of hormone in the blood,1501498,CDM,300,RC,83002,HCPCS,outpatient,,,230.02,138.01,,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.08,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.3,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,207.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,207.02,
LIBRIUM,1500288,CDM,300,RC,80346,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.03,315.94,
LIDOCAINE,1500280,CDM,300,RC,80176,HCPCS,outpatient,,,96.44,57.86,,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.9,86.8,
LIPASE,1500052,CDM,300,RC,83690,HCPCS,outpatient,,,201.88,121.13,,151.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,151.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,181.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.58,181.69,
LIPASE (FLUID),1502054,CDM,300,RC,83690,HCPCS,outpatient,,,39.06,23.44,,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.58,35.15,
LIPASE- URINE,1501322,CDM,300,RC,83690,HCPCS,outpatient,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,36.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.58,36.88,
"Blood test, lipids (cholesterol and triglycerides)",1501174,CDM,300,RC,80061,HCPCS,outpatient,,,59.74,35.84,,44.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,53.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.85,53.77,
LIPOPROTEIN (A),1502028,CDM,300,RC,83695,HCPCS,outpatient,,,107.64,64.58,,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,96.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.6,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.6,96.88,
LISTERIA MONOCYTOGENES ANTIBODY,1500470,CDM,300,RC,86723,HCPCS,outpatient,,,169.37,101.62,,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,152.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,152.43,
LITHIUM,1500116,CDM,300,RC,80178,HCPCS,outpatient,,,133.03,79.82,,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,119.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,119.73,
Liver function blood test panel,1500244,CDM,300,RC,80076,HCPCS,outpatient,,,229.69,137.81,,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.49,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,206.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.62,206.72,
LIVER-KIDNEY MICROSOME ANTIBODY,1501468,CDM,300,RC,86376,HCPCS,outpatient,,,59.82,35.89,,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,53.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.79,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.79,53.84,
LOVENOX,1501912,CDM,300,RC,85520,HCPCS,outpatient,,,477.52,286.51,,358.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,358.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,429.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,358.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.6,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.6,429.77,
LS RATIO,1500271,CDM,300,RC,83661,HCPCS,outpatient,,,250.78,150.47,,188.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,188.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,225.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.81,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.3,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.81,225.7,
Testing for presence of drug,1500176,CDM,300,RC,80307,HCPCS,outpatient,,,147.79,88.67,,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,133.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,133.01,
Testing for presence of drug,1501995,CDM,300,RC,80307,HCPCS,outpatient,,,182.76,109.66,,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,164.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,164.48,
LUDIOMIL,1500354,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
Blood test to determine genetic material of certain infectious agents,1502369,CDM,300,RC,87801,HCPCS,outpatient,,,95.61,57.37,,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,91.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,59.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,71.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,56.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,56.86,91.26,
Blood test to determine genetic material of certain infectious agents,1500471,CDM,300,RC,87801,HCPCS,outpatient,,,230.29,138.17,,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,91.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,59.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,71.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,207.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,56.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,70.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,56.86,207.26,
LYMPHOCYTE SUBSET CD4,1502334,CDM,300,RC,86356,HCPCS,outpatient,,,96.16,57.7,,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.81,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.69,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.69,86.54,
LYMPHOCYTE SUBSET CD8,1502335,CDM,300,RC,86356,HCPCS,outpatient,,,96.16,57.7,,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.81,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.69,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.69,86.54,
LYMPHOCYTIC CHORIOMENIGITIS,1501756,CDM,300,RC,86727,HCPCS,outpatient,,,66.12,39.67,,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.66,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,59.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.5,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.5,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,59.51,
LYMPHOGRNULOMA VENEREUM TITER,1501802,CDM,300,RC,87270,HCPCS,outpatient,,,160.63,96.38,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,144.57,
LYSOZYME,1500235,CDM,300,RC,85549,HCPCS,outpatient,,,291.22,174.73,,218.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.38,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,218.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.66,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,262.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,218.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.19,262.1,
MAC (AFB BLOOD CULTURE),1501881,CDM,300,RC,87116,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,11.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.75,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.75,98.09,
MAGNESIUM 24HR URINE W/O CREAT (11322),1502495,CDM,300,RC,8373590,HCPCS,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.61,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.48,6.49,
MAGNESIUM-SERUM,1500117,CDM,300,RC,83735,HCPCS,outpatient,,,33.99,20.39,,25.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.83,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,30.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,25.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.43,30.59,
MAGNESIUM-URINE,1500118,CDM,300,RC,83735,HCPCS,outpatient,,,947.67,568.6,,710.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,758.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,710.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.83,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,852.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,710.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,710.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,710.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,710.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.43,852.9,
MALARIA SMEAR,1500080,CDM,300,RC,87207,HCPCS,outpatient,,,84.69,50.81,,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,76.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.85,76.22,
MANGANESE/SERUM,1501801,CDM,300,RC,83785,HCPCS,outpatient,,,100.26,60.16,,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,37.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,90.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.59,90.23,
MANNAN BINDING LECTIN PATH FXN (C46),1502497,CDM,300,RC,8616190,HCPCS,outpatient,,,154.5,92.7,,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,139.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.25,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.66,139.05,
Blood test to assess for infection,1500269,CDM,300,RC,85007,HCPCS,outpatient,,,44.88,26.93,,33.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,40.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.08,40.39,
Blood test to assess for infection,1501934,CDM,300,RC,85007,HCPCS,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.08,13.91,
MANUAL WBC,1501927,CDM,300,RC,85032,HCPCS,outpatient,,,53.82,32.29,,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,48.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.49,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.49,48.44,
MAPLE BOX ELDER IGE SPEC ALLERGEN (T1),1501220,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
Blood test to determine if antibodies exist for measles,1501716,CDM,300,RC,86765,HCPCS,outpatient,,,130.85,78.51,,98.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,98.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,117.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,98.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,117.77,
Testing for presence of drug,1502126,CDM,300,RC,80307,HCPCS,outpatient,,,101.62,60.97,,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,91.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,91.46,
Testing for presence of drug,1502120,CDM,300,RC,80307,HCPCS,outpatient,,,221.29,132.77,,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,199.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,199.16,
MERCURY,1500492,CDM,300,RC,83825,HCPCS,outpatient,,,213.63,128.18,,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.58,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,192.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.17,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.17,192.27,
MESTANTOIN,1500493,CDM,300,RC,80299,HCPCS,outpatient,,,228.93,137.36,,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,206.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,206.04,
"METANEPHRINES, PLASMA(FREE)",1502009,CDM,300,RC,83835,HCPCS,outpatient,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,173.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,173.58,
"METANEPHRINES,FRACT.",1500256,CDM,300,RC,83835,HCPCS,outpatient,,,405.95,243.57,,304.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,304.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,365.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,304.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,304.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,365.36,
"METANEPHRINES,TOTAL",1500214,CDM,300,RC,83835,HCPCS,outpatient,,,183.04,109.82,,137.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,137.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,164.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,164.74,
"METAPNEUMOVIRUS, DFA",1502117,CDM,300,RC,87299,HCPCS,outpatient,,,287.66,172.6,,215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,258.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.04,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.04,258.89,
METHADONE,1501895,CDM,300,RC,80358,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.94,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.74,315.94,
METHEMOGLOBIN,1501812,CDM,300,RC,83050,HCPCS,outpatient,,,29.78,17.87,,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.36,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.64,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.64,26.8,
METHYL ALCOHOL,1501758,CDM,300,RC,80320,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.37,315.94,
METHYLENETETRAHYDROFOLATE REDUCTASE,1502141,CDM,300,RC,81291,HCPCS,outpatient,,,313.61,188.17,,235.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,84.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,235.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,66.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,282.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,52.93,90,,,fee schedule,90% UHC fee schedule for outpatient setting,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,65.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,282.25,
METHYLMALONIC 24 HOUR URINE,1501417,CDM,300,RC,83918,HCPCS,outpatient,,,158.44,95.06,,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,142.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.12,142.6,
METHYLMALONIC ACID,1501408,CDM,300,RC,82131,HCPCS,outpatient,,,467.41,280.45,,350.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,350.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.43,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,420.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,350.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.61,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.61,420.67,
MEXILITENE,1500494,CDM,300,RC,80299,HCPCS,outpatient,,,146.19,87.71,,109.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,109.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,131.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,109.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,131.57,
MHPG,1500364,CDM,300,RC,84999,HCPCS,outpatient,,,299.41,179.65,,224.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,224.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,269.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,224.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.35,269.47,
MI-2 AUTOANTIBODIES,1502356,CDM,300,RC,86235,HCPCS,outpatient,,,114.73,68.84,,86.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,86.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,103.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,103.26,
Urine test to measure albumin,1501387,CDM,300,RC,82043,HCPCS,outpatient,,,78.14,46.88,,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.68,70.33,
Urine test to measure albumin,1502024,CDM,300,RC,82043,HCPCS,outpatient,,,23.76,14.26,,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,21.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.68,21.38,
"MICROALBUMIN, 24 URINE",1502062,CDM,300,RC,,,outpatient,,,23.76,14.26,,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.87,21.38,
MMR PANEL,1502116,CDM,300,RC,86735,HCPCS,outpatient,,,65.29,39.17,,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.94,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,58.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,58.76,
MOLECULAR DIAGNOSTICS,1501954,CDM,300,RC,83890,HCPCS,outpatient,,,175.66,105.4,,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.99,158.09,
MONO,1500053,CDM,300,RC,86308,HCPCS,outpatient,,,121.01,72.61,,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,108.91,
MOUNTAIN CEDAR IGE SPEC ALLERGEN (T6),1501221,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
MOUSE URINE PROTEINS IGE SPEC ALLERGEN,1501222,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
Medical test to find an infection,1502113,CDM,300,RC,87081,HCPCS,outpatient,,,46.35,27.81,,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,41.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.37,41.72,
MUMPS VIRAL ANTIBODI,1500376,CDM,300,RC,86735,HCPCS,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.94,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,97.11,
MYCOBACTERIA TB,1502166,CDM,300,RC,87556,HCPCS,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,42.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.4,72.04,
MYCOPHENOLIC ACID,1501943,CDM,300,RC,80299,HCPCS,outpatient,,,301.32,180.79,,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,271.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,271.19,
MYCOPHENOLIC ACID (LS/MS/MS) (10662),1502472,CDM,300,RC,8018090,HCPCS,outpatient,,,51.5,30.9,,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.55,46.35,
MYCOPLASMA IgG,1500495,CDM,300,RC,86171,HCPCS,outpatient,,,167.47,100.48,,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,150.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.11,150.72,
MYCOPLASMA IgM,1501962,CDM,300,RC,86738,HCPCS,outpatient,,,167.47,100.48,,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.24,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,150.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.73,150.72,
MYELIN BASIC PROTEIN,1501444,CDM,300,RC,83873,HCPCS,outpatient,,,74.58,44.75,,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.93,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.93,67.12,
MYOGLOBIN (URINE),1500315,CDM,300,RC,83874,HCPCS,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.73,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.47,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.47,96.63,
MYOGLOBIN SERUM,1501335,CDM,300,RC,83874,HCPCS,outpatient,,,29.87,17.92,,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.73,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.47,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.47,26.88,
MYSOLINE LEVEL,1500226,CDM,300,RC,80188,HCPCS,outpatient,,,78.4,47.04,,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.44,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.44,70.56,
N-TELOPEPTIDE,1502014,CDM,300,RC,82523,HCPCS,outpatient,,,263.07,157.84,,197.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.51,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,197.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.05,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,236.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,197.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,197.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.13,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.13,236.76,
N-TELOPEPTIDE (900667),1502406,CDM,300,RC,8252390,HCPCS,outpatient,,,135.5,81.3,,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,67.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,121.95,
N. GONORRHOEAE AMP PROB,1502422,CDM,300,RC,8759190,HCPCS,outpatient,,,42.44,25.46,,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.22,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,38.2,
NAFCILLIN,1501333,CDM,300,RC,80299,HCPCS,outpatient,,,378.08,226.85,,283.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,283.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,340.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,283.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,340.27,
NARCOLEPSY HLA (DNA PANEL),1501814,CDM,300,RC,81383,HCPCS,outpatient,,,444.2,266.52,,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,109.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,141.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,198.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,198.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,199.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,111.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,399.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,109.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,197.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,88.4,90,,,fee schedule,90% UHC fee schedule for outpatient setting,109.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,197.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,109.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,88.4,399.78,
Test of body fluid other than blood to assess for bacteria,1501743,CDM,300,RC,87070,HCPCS,outpatient,,,155.72,93.43,,116.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,116.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,140.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,140.15,
"NATURAL KILLER CELLS, TOTAL COUNT",1502460,CDM,300,RC,8635790,HCPCS,outpatient,,,31.93,19.16,,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,28.74,
NEBCIN LEVEL,1500238,CDM,300,RC,80200,HCPCS,outpatient,,,99.44,59.66,,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,89.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.07,89.5,
Blood test for an STD,1501979,CDM,300,RC,87591,HCPCS,outpatient,,,80.04,48.02,,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,72.04,
NEONATAL BILIRUBIN,1500478,CDM,300,RC,82247,HCPCS,outpatient,,,57.64,34.58,,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.67,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,51.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.07,51.88,
NEPHELOMETRY,1501946,CDM,300,RC,83883,HCPCS,outpatient,,,71.03,42.62,,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.02,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.02,63.93,
"NEPHLOMETRY, EA ANALYTE",1502412,CDM,300,RC,83883,HCPCS,outpatient,,,37.15,22.29,,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,33.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.02,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.02,33.44,
NETROMYCIN,1500432,CDM,300,RC,80299,HCPCS,outpatient,,,136.31,81.79,,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,122.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,122.68,
NETTLE IGE SPEC ALLERGEN (W20),1501223,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
NEURONTIN (GABAPENTIN),1501416,CDM,300,RC,80171,HCPCS,outpatient,,,176.2,105.72,,132.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.17,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,132.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,158.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.55,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,158.58,
NEUROTIN,1501510,CDM,300,RC,80171,HCPCS,outpatient,,,210.36,126.22,,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.17,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,189.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.55,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,189.32,
NEWBORN METABOLIC SCREENING,1750011,CDM,300,RC,S3620,HCPCS,outpatient,,,83.05,49.83,,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.02,74.75,
NICOTINE,1501889,CDM,300,RC,80323,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.48,315.94,
NICOTINE / COTININE SERUM,1501806,CDM,300,RC,80323,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.48,315.94,
NITROGEN-TOTAL (URINE),1501747,CDM,300,RC,82397,HCPCS,outpatient,,,144.79,86.87,,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,130.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.44,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.44,130.31,
NMO-1gg (NEURO MYELITIS OPTICA),1502047,CDM,300,RC,86255,HCPCS,outpatient,,,691.97,415.18,,518.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,518.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,622.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,518.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,518.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,622.77,
NORPACE LEVEL,1500336,CDM,300,RC,80299,HCPCS,outpatient,,,91.25,54.75,,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,82.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,82.13,
NORPRAMIN,1501509,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
NORTRYPTYLINE (AVENTYL) (PAMELOR),1500551,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
NORWALK VIRUS,1501913,CDM,300,RC,87449,HCPCS,outpatient,,,81.13,48.68,,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,73.02,
NT-PRO BNP (11188),1502464,CDM,300,RC,8388090,HCPCS,outpatient,,,92.7,55.62,,69.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.35,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.99,83.43,
NUCLEIC ACID PROBE TEST,1501939,CDM,300,RC,83896,HCPCS,outpatient,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.18,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.91,43.52,
OAK IGE SPEC ALLERGEN (T7),1501224,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
OCCULT BLOOD,1500054,CDM,300,RC,82272,HCPCS,outpatient,,,7.21,4.33,,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,6.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.43,6.49,
OLANZAPINE (QUEST),1502402,CDM,300,RC,80342,HCPCS,outpatient,,,80.87,48.52,,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.79,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.59,72.78,
OLIGOCLONAL BANDING,1501440,CDM,300,RC,83916,HCPCS,outpatient,,,83.33,50,,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.19,75,
Testing for presence of drug,1502037,CDM,300,RC,80307,HCPCS,outpatient,,,38.8,23.28,,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,34.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.1,80.78,
ORGANIC ACID,1501952,CDM,300,RC,83918,HCPCS,outpatient,,,634.6,380.76,,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,571.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.12,571.14,
ORGANO PHOSPHATE PESTICIDE,1501878,CDM,300,RC,84105,HCPCS,outpatient,,,599.37,359.62,,449.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,479.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,449.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,539.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,449.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,449.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.68,539.43,
OSMOLALITY (SERUM),1500285,CDM,300,RC,83930,HCPCS,outpatient,,,42.89,25.73,,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,38.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,38.6,
OSMOLALITY (URINE),1501922,CDM,300,RC,83935,HCPCS,outpatient,,,42.89,25.73,,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.41,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,38.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.53,38.6,
OSMOTIC FRAGILITY,1500503,CDM,300,RC,85557,HCPCS,outpatient,,,180.85,108.51,,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,162.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.82,162.77,
OVA & PARASITES,1500055,CDM,300,RC,87177,HCPCS,outpatient,,,46.35,27.81,,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,41.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.9,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,41.72,
OXCARBAZEPINE METABOLITE,1501766,CDM,300,RC,80183,HCPCS,outpatient,,,115.83,69.5,,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,104.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,104.25,
p ANTI DNA,1502302,CDM,300,RC,86225,HCPCS,outpatient,,,56.28,33.77,,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.13,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.13,50.65,
p ANTI NUCLEAR ABS,1502308,CDM,300,RC,86038,HCPCS,outpatient,,,48.89,29.33,,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.79,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.79,44,
p ANTI SCL-70 ABS,1502305,CDM,300,RC,86235,HCPCS,outpatient,,,74.03,44.42,,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,66.63,
p ANTI SM ABS,1502303,CDM,300,RC,86235,HCPCS,outpatient,,,74.03,44.42,,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,66.63,
p ANTI SM/RNP ABS,1502304,CDM,300,RC,86235,HCPCS,outpatient,,,74.03,44.42,,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,66.63,
p ANTI SSA ABS,1502306,CDM,300,RC,86235,HCPCS,outpatient,,,74.03,44.42,,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,66.63,
p ANTI SSB ABS,1502307,CDM,300,RC,86235,HCPCS,outpatient,,,74.03,44.42,,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,66.63,
p RA FACTOR,1502301,CDM,300,RC,86431,HCPCS,outpatient,,,22.67,13.6,,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,20.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.59,20.4,
P. NOTATUM IGE SPEC ALLERGEN (M1),1501226,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
PANCREATIC ELASTASE FECAL,1501997,CDM,300,RC,82656,HCPCS,outpatient,,,438.46,263.08,,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,93.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,394.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,394.61,
PARAINFLUENZA VIRUS,1500396,CDM,300,RC,87279,HCPCS,outpatient,,,71.03,42.62,,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.31,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.31,63.93,
PARATHYROID HORMONE INTACT,1500154,CDM,300,RC,83970,HCPCS,outpatient,,,72.1,43.26,,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,62.95,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.95,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.06,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,42.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.44,90,,,fee schedule,90% UHC fee schedule for outpatient setting,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,41.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.44,64.89,
PARATHYROID HORMONE RELATED PROTEIN,1502104,CDM,300,RC,83519,HCPCS,outpatient,,,345.3,207.18,,258.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,276.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,258.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,310.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,310.77,
PARIETAL CELL TOTAL AUTOANTIBODY,1501749,CDM,300,RC,86255,HCPCS,outpatient,,,100.53,60.32,,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,90.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,90.48,
PARVO VIRUS IgG,1501891,CDM,300,RC,86747,HCPCS,outpatient,,,60.91,36.55,,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.18,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.18,54.82,
PARVO VIRUS IgM,1501892,CDM,300,RC,86747,HCPCS,outpatient,,,60.91,36.55,,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.18,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.18,54.82,
PARVOVIRUS HUMAN SERUM IGG & IGM,1501330,CDM,300,RC,86747,HCPCS,outpatient,,,334.82,200.89,,251.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,251.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,301.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,251.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.18,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.18,301.34,
PATERNITY ADDITIONAL,1500253,CDM,300,RC,,,outpatient,,,1034,620.4,,775.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,220.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,220.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,775.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,930.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,775.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,775.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,651.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.87,930.6,
PATERNITY DETERMIN,1500227,CDM,300,RC,86910,HCPCS,outpatient,,,1835.5,1101.3,,1376.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1468.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1376.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.49,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1651.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1376.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1376.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1376.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1376.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.64,90,,,fee schedule,90% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,1651.95,
PATERNITY TEST DRAWING FEE,1501383,CDM,300,RC,,,outpatient,,,53,31.8,,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.86,47.7,
PATHOLOGIST REVIEW,1501999,CDM,300,RC,80500,HCPCS,outpatient,,,100.26,60.16,,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.13,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,90.23,
PBG DEAMINASE IN RBC'S,1501344,CDM,300,RC,84311,HCPCS,outpatient,,,578.32,346.99,,433.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,433.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,520.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,433.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.56,520.49,
PECAN/HICKORY IGE SPEC ALLERGEN (T22),1501225,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
PERIPHERAL BLOOD SMEAR,1502110,CDM,300,RC,85060,HCPCS,outpatient,,,69.11,41.47,,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.46,62.2,
PERTUSIS/PARA PERTUS DNA QUAL RT PCR,1502069,CDM,300,RC,87798,HCPCS,outpatient,,,652.36,391.42,,489.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,521.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,489.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,587.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,489.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,587.12,
PERTUSSIS,1502132,CDM,300,RC,87798,HCPCS,outpatient,,,295.31,177.19,,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,265.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,265.78,
PERTUSSIS ANTIBODY IqG,1502140,CDM,300,RC,86615,HCPCS,outpatient,,,86.05,51.63,,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.12,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.68,77.45,
Medical test to find an infection,1501295,CDM,300,RC,87081,HCPCS,outpatient,,,149.7,89.82,,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,134.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.63,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.37,134.73,
PG (PHOSPHATIDYLGLYCEROL),1501470,CDM,300,RC,84081,HCPCS,outpatient,,,193.41,116.05,,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,174.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.38,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.38,174.07,
PH (URINE),1500138,CDM,300,RC,83986,HCPCS,outpatient,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,24.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.9,24.1,
pH BODY FLUID,1501384,CDM,300,RC,83986,HCPCS,outpatient,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,24.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.9,24.1,
PHENALYLANINE,1500175,CDM,300,RC,84030,HCPCS,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.41,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.46,92.44,
Testing for presence of drug,1502042,CDM,300,RC,80307,HCPCS,outpatient,,,38.8,23.28,,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,34.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.1,80.78,
PHENOBARBITAL,1500127,CDM,300,RC,80184,HCPCS,outpatient,,,83.05,49.83,,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.89,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.39,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.39,74.75,
PHENYTOIN,1501486,CDM,300,RC,80185,HCPCS,outpatient,,,122.66,73.6,,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,110.39,
PHOSPHOLIPIDS,1500233,CDM,300,RC,84311,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.56,120.23,
PHOSPHORUS,1500056,CDM,300,RC,84100,HCPCS,outpatient,,,32.96,19.78,,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.83,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,29.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.84,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.84,29.66,
PINWORM PREP,1500497,CDM,300,RC,87172,HCPCS,outpatient,,,68.85,41.31,,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,61.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,61.97,
PLASMA HEMOGLOBIN,1500276,CDM,300,RC,83051,HCPCS,outpatient,,,49.99,29.99,,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.92,44.99,
PLASMA NOREPINEPHRINE,1501397,CDM,300,RC,82383,HCPCS,outpatient,,,202.43,121.46,,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,38.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.28,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,29.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,182.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.55,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.55,182.19,
PLASMINOGEN ACTIVATOR,1501941,CDM,300,RC,85415,HCPCS,outpatient,,,598,358.8,,448.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,478.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.35,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,448.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,538.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,448.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.92,538.2,
PLATELET ANTIBODIES,1500565,CDM,300,RC,86022,HCPCS,outpatient,,,418.79,251.27,,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,376.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.88,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.88,376.91,
PLATELET COUNT,1500057,CDM,300,RC,85049,HCPCS,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.84,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.63,39.83,
PNEUMOCYSTIS CARNII PCR,1501386,CDM,300,RC,87798,HCPCS,outpatient,,,254.33,152.6,,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,228.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,228.9,
PNEUMONITIS HYPERSENSITIVITY MIXED PANEL,1502100,CDM,300,RC,86606,HCPCS,outpatient,,,578.87,347.32,,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,520.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,434.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.2,520.98,
PNH WITH FLAER,1502119,CDM,300,RC,88184,HCPCS,outpatient,,,1291.33,774.8,,968.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1033.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,968.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.01,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1162.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,968.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,968.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,968.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,968.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,1162.2,
PORPHOBILINOGEN,1500498,CDM,300,RC,84106,HCPCS,outpatient,,,113.64,68.18,,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.54,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.54,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,102.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.49,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.49,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.72,102.28,
PORPHYRINS PLASMA,1501467,CDM,300,RC,82542,HCPCS,outpatient,,,358.97,215.38,,269.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.16,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,269.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,24.57,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,323.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,269.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.51,90,,,fee schedule,90% UHC fee schedule for outpatient setting,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,323.07,
"PORPHYRINS, 24HR URI",1500171,CDM,300,RC,84119,HCPCS,outpatient,,,185.22,111.13,,138.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.37,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,138.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,166.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.82,166.7,
POST VASECTOMY SCREEN,1501899,CDM,300,RC,89320,HCPCS,outpatient,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.55,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,43.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,43.52,
POST-VASECTOMY SPERM ANALYSIS,1501398,CDM,300,RC,89320,HCPCS,outpatient,,,78.4,47.04,,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.55,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,70.56,
POTASSIUM 24 HR URINE,1502071,CDM,300,RC,84133,HCPCS,outpatient,,,39.06,23.44,,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.82,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.83,35.15,
POTASSIUM RANDOM URINE,1502050,CDM,300,RC,84133,HCPCS,outpatient,,,39.06,23.44,,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.82,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.83,35.15,
"POTASSIUM, SERUM",1500059,CDM,300,RC,84132,HCPCS,outpatient,,,24.72,14.83,,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.19,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,22.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.85,22.25,
PRADERWILLI/ANGELMAN SYNDROME,1502137,CDM,300,RC,81331,HCPCS,outpatient,,,992.48,595.49,,744.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,793.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,51.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.39,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,744.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,52.09,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,893.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,744.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,744.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,41.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,51.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,51.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.36,893.23,
Blood test to measure level of prealbumin,1500557,CDM,300,RC,84134,HCPCS,outpatient,,,109.55,65.73,,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.28,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.82,98.6,
PREGNENOLONE LC/MS (31493),1502467,CDM,300,RC,8414090,HCPCS,outpatient,,,60.77,36.46,,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.45,54.69,
Obstetric blood test panel,1500135,CDM,300,RC,80055,HCPCS,outpatient,,,194.51,116.71,,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,47.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,48.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,175.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,47.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,47.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.83,175.06,
PRETREATMENT W/CHEM,1501736,CDM,300,RC,86970,HCPCS,outpatient,,,202.16,121.3,,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,43.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,181.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,181.94,
PRETREATMENT W/ENZYME,1501737,CDM,300,RC,86971,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,98.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,98.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.16,417.97,
PREVENTATIVE MED DRG SCR FEE,1501753,CDM,300,RC,,,outpatient,,,24.04,14.42,,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,21.64,
PRIMIDONE,1501713,CDM,300,RC,80188,HCPCS,outpatient,,,68.02,40.81,,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,61.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.44,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.59,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.44,61.22,
PROCAINAMIDE,1500314,CDM,300,RC,80190,HCPCS,outpatient,,,90.16,54.1,,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,61.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,81.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,48.6,90,,,fee schedule,90% UHC fee schedule for outpatient setting,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.39,81.14,
PROCALCITONIN,1502409,CDM,300,RC,84145,HCPCS,outpatient,,,74.3,44.58,,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.39,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,66.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,66.87,
PROGESTERONE,1500293,CDM,300,RC,84144,HCPCS,outpatient,,,162.54,97.52,,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,146.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.89,146.29,
Test is used to measure the amount of the drug in the blood to determine whether the concentration has reached a therapeutic level and is below the to,1501852,CDM,300,RC,80197,HCPCS,outpatient,,,184.95,110.97,,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,166.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.12,166.46,
PROINSULIN LEVEL,1501835,CDM,300,RC,84206,HCPCS,outpatient,,,228.93,137.36,,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,206.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.62,206.04,
PROLACTIN LEVEL,1500237,CDM,300,RC,84146,HCPCS,outpatient,,,213.63,128.18,,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.19,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,192.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.38,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.7,192.27,
PROLIXIN,1500499,CDM,300,RC,80342,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.79,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.59,315.94,
PRONESTYL,1500182,CDM,300,RC,80190,HCPCS,outpatient,,,100.81,60.49,,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,61.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,90.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,48.6,90,,,fee schedule,90% UHC fee schedule for outpatient setting,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,60,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.39,90.73,
PROPAFENONE,1501807,CDM,300,RC,80299,HCPCS,outpatient,,,78.67,47.2,,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,70.8,
PROSTATIC ACID PHOS,1500500,CDM,300,RC,84066,HCPCS,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.56,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.82,97.11,
PROTEIN C ACTIVITY,1501888,CDM,300,RC,85303,HCPCS,outpatient,,,244.23,146.54,,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.13,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,219.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.84,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.21,219.81,
PROTEIN C AND S PANEL,1501296,CDM,300,RC,,,outpatient,,,48.89,29.33,,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.8,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.02,44,
PROTEIN C ANTIGEN,1501894,CDM,300,RC,85302,HCPCS,outpatient,,,244.23,146.54,,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.34,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.34,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.37,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,219.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.73,219.81,
PROTEIN ELECT. SERUM,1501447,CDM,300,RC,84165,HCPCS,outpatient,,,74.58,44.75,,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.41,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.7,67.12,
PROTEIN ELECTROPHERESIS 24HR URINE,1501839,CDM,300,RC,84166,HCPCS,outpatient,,,74.58,44.75,,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.45,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.45,67.12,
PROTEIN ELECTROPHERESIS RANDOM URINE,1500375,CDM,300,RC,84156,HCPCS,outpatient,,,150.52,90.31,,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,135.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.97,135.47,
PROTEIN ELECTROPHORESIS,1502414,CDM,300,RC,84166,HCPCS,outpatient,,,49.17,29.5,,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.45,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.03,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.45,44.25,
PROTEIN S,1502443,CDM,300,RC,85306,HCPCS,outpatient,,,15.91,9.55,,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.41,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,14.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.93,23.41,
"PROTEIN S, FREE",1502023,CDM,300,RC,85306,HCPCS,outpatient,,,244.23,146.54,,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.41,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,219.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.41,219.81,
"PROTEIN S, TOTAL",1502162,CDM,300,RC,85305,HCPCS,outpatient,,,244.23,146.54,,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.71,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,219.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.41,219.81,
"PROTEIN, RANDOM URINE",1502064,CDM,300,RC,84156,HCPCS,outpatient,,,83.59,50.15,,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,75.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.97,75.23,
"PROTEIN,24 HR UR",1500139,CDM,300,RC,84156,HCPCS,outpatient,,,83.59,50.15,,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,75.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.97,75.23,
PROTEUS OX 19,1501961,CDM,300,RC,86000,HCPCS,outpatient,,,35.25,21.15,,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,31.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,31.73,
PROTHROMBIN GENE ANALYSIS,1502077,CDM,300,RC,81240,HCPCS,outpatient,,,260.89,156.53,,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.4,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,234.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,53.21,90,,,fee schedule,90% UHC fee schedule for outpatient setting,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,65.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,234.8,
"Blood test, clotting time",1500062,CDM,300,RC,85610,HCPCS,outpatient,,,29.87,17.92,,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.47,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.47,26.88,
PROTOPORPHYRIN,1500373,CDM,300,RC,84202,HCPCS,outpatient,,,78.4,47.04,,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.63,70.56,
PSA (prostate specific antigen) measurement,1501949,CDM,300,RC,84154,HCPCS,outpatient,,,184.67,110.8,,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.1,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,166.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,166.2,
PSA (prostate specific antigen),1501508,CDM,300,RC,84153,HCPCS,outpatient,,,63.86,38.32,,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.1,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,57.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,57.47,
Prostate cancer screening; prostate specific antigen test (psa),1501464,CDM,300,RC,G0103,HCPCS,outpatient,,,37.08,22.25,,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,33.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.64,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.64,33.37,
"Blood test, clotting time",1501493,CDM,300,RC,85610,HCPCS,outpatient,,,101.62,60.97,,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.99,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,91.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.47,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.47,91.46,
Coagulation assessment blood test,1500063,CDM,300,RC,85730,HCPCS,outpatient,,,39.14,23.48,,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.81,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.87,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,35.23,
PYRIDOXINE (VIT B6) LEVEL,1500446,CDM,300,RC,84207,HCPCS,outpatient,,,331.65,198.99,,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,42.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,28.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,298.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.76,298.49,
PYRUVATE ACID,1501967,CDM,300,RC,84210,HCPCS,outpatient,,,160.63,96.38,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.73,144.57,
Q FEVER ANTIBODIES,1501379,CDM,300,RC,86638,HCPCS,outpatient,,,98.62,59.17,,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.53,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.36,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,88.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,88.76,
QUANTITATIVE HCG TUMOR MARKER,1502001,CDM,300,RC,84702,HCPCS,outpatient,,,26.22,15.73,,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,23.6,
QUETIAPINE (QUEST),1502403,CDM,300,RC,80299,HCPCS,outpatient,,,69.94,41.96,,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,62.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,62.95,
QUINIDINE LEVEL,1500148,CDM,300,RC,80194,HCPCS,outpatient,,,86.32,51.79,,64.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.98,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,64.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.3,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.83,77.69,
RA,1500064,CDM,300,RC,86430,HCPCS,outpatient,,,60.77,36.46,,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.98,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.98,54.69,
RARE REAGENT CELL,1501721,CDM,300,RC,86860,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,235.29,
RAST,1500180,CDM,300,RC,86003,HCPCS,outpatient,,,408.14,244.88,,306.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,306.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,367.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,367.33,
"RAST ALLERGY TEST, EACH",1502075,CDM,300,RC,86003,HCPCS,outpatient,,,39.06,23.44,,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,35.15,
RBC,1500136,CDM,300,RC,85041,HCPCS,outpatient,,,17.61,10.57,,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,15.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.45,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.45,15.85,
RBC FOLATE,1500131,CDM,300,RC,82747,HCPCS,outpatient,,,224.56,134.74,,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.95,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.46,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,202.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.3,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.3,202.1,
RECIP. SET,1501729,CDM,300,RC,,,outpatient,,,9.56,5.74,,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,8.6,
Blood test to screen for antibodies that could harm red blood cells,1500266,CDM,300,RC,86850,HCPCS,outpatient,,,188.5,113.1,,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,169.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.91,169.65,
REFERENCE ABO GROUP SR86900,1501474,CDM,300,RC,86900,HCPCS,outpatient,,,77.04,46.22,,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.56,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,69.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.42,132.76,
REFERENCE AHG CROSSMATCH SR 86922,1501710,CDM,300,RC,86921,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,235.29,
REFERENCE ANTIBODY PANEL SR 86870,1501473,CDM,300,RC,86870,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,417.97,
Blood test to screen for antibodies that could harm red blood cells,1501741,CDM,300,RC,86850,HCPCS,outpatient,,,188.5,113.1,,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,169.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.91,169.65,
"REFERENCE ANTIGEN TYPING, COMMON",1501733,CDM,300,RC,86902,HCPCS,outpatient,,,60.91,36.55,,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,54.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.15,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.15,370.6,
"REFERENCE ANTIGEN TYPING, HIGH INCIDENCE",1501734,CDM,300,RC,86902,HCPCS,outpatient,,,479.71,287.83,,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.15,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.15,431.74,
REFERENCE ASAP CHARGE,1501394,CDM,300,RC,86999,HCPCS,outpatient,,,105.72,63.43,,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,95.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,95.15,
REFERENCE DAT SR 86880,1501477,CDM,300,RC,86880,HCPCS,outpatient,,,57.09,34.25,,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,51.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.37,65.72,
REFERENCE DILUTION SERUM SR86976,1502025,CDM,300,RC,86976,HCPCS,outpatient,,,71.57,42.94,,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.66,64.41,
REFERENCE INDIRECT TITER SR86886,1502026,CDM,300,RC,86886,HCPCS,outpatient,,,113.92,68.35,,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,102.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,179.8,
REFERENCE OVERTIME CHARGE PER HOUR,1501361,CDM,300,RC,86999,HCPCS,outpatient,,,123.2,73.92,,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,110.88,
"REFERENCE PHENOTYPE COMPLETE (D,C,E,c,e)",1501478,CDM,300,RC,86906,HCPCS,outpatient,,,57.09,34.25,,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,51.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.28,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.28,51.38,
REFERENCE RETIC SEPARATION,1501769,CDM,300,RC,86972,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.57,235.29,
REFERENCE Rh PHENOTYPE,1501476,CDM,300,RC,86906,HCPCS,outpatient,,,189.31,113.59,,141.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,141.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,170.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.28,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.28,170.38,
REFERENCE Rh TYPE SR86901,1501475,CDM,300,RC,86901,HCPCS,outpatient,,,56.28,33.77,,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.63,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.42,50.65,
REFERENCE SALINE WASHING,1500456,CDM,300,RC,86999,HCPCS,outpatient,,,224.56,134.74,,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,179.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,47.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,202.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,46.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,46.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,202.1,
REFERENCE SERVICE FEE SREF400,1501353,CDM,300,RC,86999,HCPCS,outpatient,,,814.64,488.78,,610.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,173.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,173.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,610.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,733.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,610.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,610.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,610.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,610.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,733.18,
REFERENCE SICKLE CELL SCREEN SUR2,1501735,CDM,300,RC,85660,HCPCS,outpatient,,,45.35,27.21,,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.43,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,40.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.46,40.82,
REFERENCE STAT CHARGE,1501393,CDM,300,RC,86999,HCPCS,outpatient,,,314.16,188.5,,235.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,66.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,282.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,282.74,
Basic metabolic panel,1502434,CDM,300,RC,80048,HCPCS,outpatient,,,312.17,187.3,,234.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,234.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,280.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,234.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.46,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.85,280.95,
RENIN,1500132,CDM,300,RC,84244,HCPCS,outpatient,,,273.45,164.07,,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,246.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.81,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.81,246.11,
"RESPIRATORY SYNCTIAL VIRUS RNA, QUAL PCR",1502070,CDM,300,RC,87798,HCPCS,outpatient,,,116.1,69.66,,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,104.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,104.49,
RESPIRATORY VIRAL PANEL,1500450,CDM,300,RC,87633,HCPCS,outpatient,,,1490.76,894.46,,1118.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1192.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,541.81,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,235.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,235.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1118.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,425.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1341.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1118.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1118.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1118.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1118.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,233.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,337.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,233.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,416.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,233.63,1341.68,
RESTORIL,1500430,CDM,300,RC,80299,HCPCS,outpatient,,,183.3,109.98,,137.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,137.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,164.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,164.97,
RETIC,1500066,CDM,300,RC,85044,HCPCS,outpatient,,,19.57,11.74,,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.56,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,17.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.49,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.49,17.61,
RETICULIN ANTIBODY IGA,1501843,CDM,300,RC,86255,HCPCS,outpatient,,,48.89,29.33,,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,44,
RETICULIN ANTIBODY IGG,1501844,CDM,300,RC,86255,HCPCS,outpatient,,,48.89,29.33,,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,44,
REVERSE TRANSCRIPTION BCR/ABL,1501829,CDM,300,RC,81206,HCPCS,outpatient,,,666.29,399.77,,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,213.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,119.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.56,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,167.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,599.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,499.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,132.8,90,,,fee schedule,90% UHC fee schedule for outpatient setting,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,599.66,
RIBOFLAVIN,1501466,CDM,300,RC,84252,HCPCS,outpatient,,,130.04,78.02,,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,117.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.4,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.4,117.04,
RICKETTSIAL ANTIBODY,1501323,CDM,300,RC,86256,HCPCS,outpatient,,,261.71,157.03,,196.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,196.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.77,235.54,
RISTOCETIN COFACTOR,1501500,CDM,300,RC,85245,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.59,337.08,
RISTOCETIN INDUCED PLATELE,1501316,CDM,300,RC,85245,HCPCS,outpatient,,,843.86,506.32,,632.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,632.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,759.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,632.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,632.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.59,759.47,
RMSF,1501512,CDM,300,RC,86000,HCPCS,outpatient,,,221.01,132.61,,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,198.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,198.91,
RNA POLYMERASE III Ab,1502057,CDM,300,RC,83520,HCPCS,outpatient,,,72.68,43.61,,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.99,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.99,65.41,
ROBAXIN LEVEL,1500337,CDM,300,RC,80299,HCPCS,outpatient,,,119.66,71.8,,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,107.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,107.69,
ROCKY MT. SPTD FEVER,1500290,CDM,300,RC,86000,HCPCS,outpatient,,,221.01,132.61,,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,198.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,165.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,198.91,
ROTAVIRUS ANTIGEN DETECTION,1500534,CDM,300,RC,87425,HCPCS,outpatient,,,152.44,91.46,,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,137.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.7,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.7,137.2,
ROUGH PIGWEED IGE SPEC ALLERGEN (W14),1501227,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
Blood test to screen for syphilis,1500068,CDM,300,RC,86592,HCPCS,outpatient,,,32.96,19.78,,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.65,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,29.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,29.66,
Test for RSV,1501520,CDM,300,RC,87807,HCPCS,outpatient,,,41.2,24.72,,30.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.36,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,37.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.61,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.61,37.08,
Blood test to determine if antibodies exist for rubella,1500230,CDM,300,RC,86762,HCPCS,outpatient,,,165.55,99.33,,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,149,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,149,
RUSSELL VIPER VENOM DILUTED,1502336,CDM,300,RC,85613,HCPCS,outpatient,,,34.69,20.81,,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.62,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,31.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.49,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.49,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.76,31.22,
S-NUCLEOTIDASE,1500496,CDM,300,RC,83915,HCPCS,outpatient,,,113.64,68.18,,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,102.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.04,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.04,102.28,
SALICYLATE,1500090,CDM,300,RC,80179,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,93.63,
Blood test to identify bacteria that may be contributing to symptoms in the gastrointestinal tract,1500452,CDM,300,RC,87046,HCPCS,outpatient,,,49.73,29.84,,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,44.76,
SARS ANTIGEN FIA,1502408,CDM,300,RC,87426,HCPCS,outpatient,,,572.68,343.61,,429.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,43.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,43.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,429.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,36.03,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,515.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,429.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,36.75,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.33,515.41,
SARS-COV-2 ANTIBODY IgG,1502404,CDM,300,RC,8676990,HCPCS,outpatient,,,80.34,48.2,,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,72.31,
SARS-COV-2 ANTIBODY IgM,1502416,CDM,300,RC,8676990,HCPCS,outpatient,,,80.34,48.2,,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.17,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,72.31,
SCABIES EXAM,1502405,CDM,300,RC,8722090,HCPCS,outpatient,,,45.9,27.54,,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.95,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.4,41.31,
SCL-70,1501764,CDM,300,RC,86235,HCPCS,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,65.64,
SCLERODERMA,1501808,CDM,300,RC,86235,HCPCS,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,65.64,
SCN KELL,1500467,CDM,300,RC,86870,HCPCS,outpatient,,,425.1,255.06,,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,382.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.37,382.59,
SEAFOOD ALLERGY PROFILE,1502153,CDM,300,RC,86003,HCPCS,outpatient,,,92.06,55.24,,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,82.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.23,82.85,
SEDRATE,1500069,CDM,300,RC,85651,HCPCS,outpatient,,,113.3,67.98,,84.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.41,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.41,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,101.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,101.97,
SELENIUM,1502435,CDM,300,RC,8425590,HCPCS,outpatient,,,26.52,15.91,,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.43,23.87,
SEMEN ANALYSIS POST VASECTOMY,1500074,CDM,300,RC,89321,HCPCS,outpatient,,,49.17,29.5,,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.77,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,44.25,
SENSITIVITY AFB,1501937,CDM,300,RC,87190,HCPCS,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.92,57.78,
A test used to determine which medications work on bacteria for fungi,1500443,CDM,300,RC,87186,HCPCS,outpatient,,,21.63,12.98,,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.82,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,19.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,19.47,
SEPARATION BY GEL,1501956,CDM,300,RC,81244,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,119.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,119.56,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,45.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,36.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.36,119.56,
SEROTONIN (SERUM),1500168,CDM,300,RC,84260,HCPCS,outpatient,,,142.87,85.72,,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,47.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,47.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,31.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,128.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,46.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.09,90,,,fee schedule,90% UHC fee schedule for outpatient setting,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,46.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,30.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.09,128.58,
Testing for presence of drug,1501767,CDM,300,RC,80307,HCPCS,outpatient,,,182.76,109.66,,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,164.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,164.48,
Blood test to assess for pregnancy,1501320,CDM,300,RC,84703,HCPCS,outpatient,,,29.87,17.92,,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.79,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.09,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.09,26.88,
SERUM TREATMENT W/CHEM,1501719,CDM,300,RC,86975,HCPCS,outpatient,,,80.32,48.19,,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.32,90,,,fee schedule,90% UHC fee schedule for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.46,431.73,
SEX HORMONE BINDING GLOBULIN,1501811,CDM,300,RC,84270,HCPCS,outpatient,,,235.49,141.29,,176.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,176.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,211.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.6,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.6,211.94,
SGOT - AST,1500070,CDM,300,RC,84450,HCPCS,outpatient,,,115.29,69.17,,86.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,86.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,103.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,86.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,103.76,
Blood test to evaluate liver function,1500071,CDM,300,RC,84460,HCPCS,outpatient,,,106.54,63.92,,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.89,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,95.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.29,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.29,95.89,
SHEEP SORREL IGE SPEC ALLERGEN (W18),1501228,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
SICKLE CELL SCREEN,1500072,CDM,300,RC,85660,HCPCS,outpatient,,,76.77,46.06,,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.43,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,69.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.46,69.09,
SINEMET,1501359,CDM,300,RC,80299,HCPCS,outpatient,,,680.77,408.46,,510.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,510.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,612.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,510.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,612.69,
SINEQUIN,1501515,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
SIROLIMUS (RAPAMUNE),1501081,CDM,300,RC,80195,HCPCS,outpatient,,,321.54,192.92,,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,289.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.12,289.39,
SIROLIMUS-RAPAMUNE-TROUGH,1501810,CDM,300,RC,80195,HCPCS,outpatient,,,321.54,192.92,,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,289.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.12,289.39,
SJORGEN'S ANTIBODIES,1501403,CDM,300,RC,86235,HCPCS,outpatient,,,139.05,83.43,,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,125.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,125.15,
SODIUM (BLOOD),1500073,CDM,300,RC,84295,HCPCS,outpatient,,,16.48,9.89,,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.34,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.34,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.9,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,14.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.9,14.83,
SODIUM (SPOT URINE),1501819,CDM,300,RC,84300,HCPCS,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.1,49.42,
SODIUM 24 HR URINE,1502072,CDM,300,RC,84300,HCPCS,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.1,49.42,
Flu test,2113198,CDM,300,RC,87804,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.41,21.52,
Flu test,2113171,CDM,300,RC,87804,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.41,21.52,
SOMATOMEDIN-C,1501313,CDM,300,RC,84305,HCPCS,outpatient,,,268.81,161.29,,201.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,201.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.68,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,241.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,201.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.22,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.22,241.93,
SOTALOL,1501836,CDM,300,RC,80375,HCPCS,outpatient,,,289.03,173.42,,216.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,216.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,260.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.99,260.13,
SPEC COLL COVID-19 ANY SOURCE,1502395,CDM,300,RC,G2023,HCPCS,outpatient,,,25.63,15.38,,19.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,2.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,23.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,2.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.08,24.3,
SPEC COLL COVID-19 ANY SOURCE SNF,1502396,CDM,300,RC,G2024,HCPCS,outpatient,,,27.82,16.69,,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.3,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.62,25.04,
SPECIFIC GRAVITY (BODY FLUID),1501869,CDM,300,RC,84315,HCPCS,outpatient,,,23.76,14.26,,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.83,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.34,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,21.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.28,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.66,21.38,
SPECIFIC GRAVITY (URINE),1500087,CDM,300,RC,81099,HCPCS,outpatient,,,11.74,7.04,,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.41,10.57,
SPECTROPHOTOMETRY,1501884,CDM,300,RC,84311,HCPCS,outpatient,,,106.28,63.77,,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,95.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.56,95.65,
SPINAL FLD-COLL.GOLD,1500221,CDM,300,RC,89060,HCPCS,outpatient,,,89.6,53.76,,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,80.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.94,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,80.64,
SPINAL FLUID CHLORID,1500076,CDM,300,RC,82438,HCPCS,outpatient,,,56,33.6,,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.05,50.4,
SPINAL FLUID GLUCOSE,1500077,CDM,300,RC,82945,HCPCS,outpatient,,,90.42,54.25,,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,81.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.19,81.38,
SPINAL FLUID PROTEIN,1500078,CDM,300,RC,84155,HCPCS,outpatient,,,90.42,54.25,,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,81.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.97,81.38,
SPOROTHRIX ANTIBODIE,1500351,CDM,300,RC,86671,HCPCS,outpatient,,,90.16,54.1,,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.74,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,81.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.93,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.93,81.14,
SPUN MICROHEMATOCRIT,1501928,CDM,300,RC,85013,HCPCS,outpatient,,,24.04,14.42,,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.62,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,21.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.67,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.59,21.64,
SPUTUM COLLECTION,2600051,CDM,300,RC,89220,HCPCS,outpatient,,,191.58,114.95,,143.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,40.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,172.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.25,179.8,
SQUAMOUS CELL CARCINOMA ANTIGEN,1501454,CDM,300,RC,86316,HCPCS,outpatient,,,84.69,50.81,,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,76.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,76.22,
SRP AUTOANTIBODIES,1502355,CDM,300,RC,86235,HCPCS,outpatient,,,104.63,62.78,,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,94.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,94.17,
SSA ANTIBODY,1502006,CDM,300,RC,86235,HCPCS,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,65.64,
SSB ANTIBODY,1502007,CDM,300,RC,86235,HCPCS,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.53,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.53,65.64,
ST. LOUIS ENCEPHALITIS IGG,1502430,CDM,300,RC,8665390,HCPCS,outpatient,,,43.5,26.1,,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,39.15,
ST. LOUIS ENCEPHALITIS IGM,1502431,CDM,300,RC,8665390,HCPCS,outpatient,,,43.5,26.1,,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,39.15,
STONE ANALYSIS,1501501,CDM,300,RC,82360,HCPCS,outpatient,,,162.54,97.52,,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,146.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,146.29,
STOOL BILE,1500079,CDM,300,RC,84577,HCPCS,outpatient,,,84.42,50.65,,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,75.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.61,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.59,75.98,
STOOL/FECAL pH,1501990,CDM,300,RC,83986,HCPCS,outpatient,,,65.84,39.5,,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.65,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.46,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.47,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,59.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.58,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.9,59.26,
STOOL/FECAL REDUCING SUBSTANCES,1500437,CDM,300,RC,84999,HCPCS,outpatient,,,52.73,31.64,,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.8,47.46,
STREP (GROUP B) SCREEN,1501906,CDM,300,RC,86403,HCPCS,outpatient,,,102.18,61.31,,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,91.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,91.96,
STREP PNEUMONIAE (14 SEROTYPES),1502157,CDM,300,RC,86317,HCPCS,outpatient,,,297.49,178.49,,223.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,223.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,267.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,223.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.14,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.14,267.74,
Test for strep A,1500504,CDM,300,RC,87880,HCPCS,outpatient,,,29.87,17.92,,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.86,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.39,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.39,26.88,
STREP SEREOTYPE EXPANDED (23 TYPES),1502098,CDM,300,RC,86317,HCPCS,outpatient,,,836.22,501.73,,627.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,668.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,627.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,752.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,627.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,627.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.14,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.14,752.6,
STREPOCCUS & MENINGOCCUS ATIGEN,1500448,CDM,300,RC,86403,HCPCS,outpatient,,,84.95,50.97,,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.13,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,76.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.35,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.35,76.46,
STREPTOZYME,1500275,CDM,300,RC,86063,HCPCS,outpatient,,,69.94,41.96,,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,62.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.67,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.67,62.95,
STRONGYLOIDIES (HELMINTH) AB,1502350,CDM,300,RC,86682,HCPCS,outpatient,,,65.29,39.17,,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,58.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.54,58.76,
"STRONTIUM, SERUM",1502049,CDM,300,RC,83018,HCPCS,outpatient,,,119.66,71.8,,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,107.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.78,107.69,
SUDAN STAIN,1500304,CDM,300,RC,89125,HCPCS,outpatient,,,68.02,40.81,,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,61.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.76,61.22,
SULFONYLUREA,1501825,CDM,300,RC,80377,HCPCS,outpatient,,,513.58,308.15,,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,410.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,109.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,462.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.23,462.22,
SYNOVIAL FLUID CRYSTAL EXAM,1500505,CDM,300,RC,89060,HCPCS,outpatient,,,66.1,39.66,,49.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,49.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,59.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.94,90,,,fee schedule,90% UHC fee schedule for outpatient setting,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.94,59.49,
SYNOVIAL FLUID MUCIN CLOT,1500519,CDM,300,RC,83872,HCPCS,outpatient,,,77.77,46.66,,58.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.97,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,69.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.74,69.99,
Blood test to evaluate thyroid function,1500414,CDM,300,RC,84439,HCPCS,outpatient,,,61.47,36.88,,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,55.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.31,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.31,55.32,
T-CELLS ABSOLUTE CD4/CD8 COUNT W/RATIO,1502462,CDM,300,RC,8636090,HCPCS,outpatient,,,31.93,19.16,,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,28.74,
T-CELLS TOTAL COUNT,1502461,CDM,300,RC,8635990,HCPCS,outpatient,,,31.93,19.16,,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.97,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.54,28.74,
T-LYMPHOCYTE ASSAY,1501336,CDM,300,RC,88184,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.01,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.55,417.97,
T-LYMPHOCYTE COUNT CD4,1500537,CDM,300,RC,86359,HCPCS,outpatient,,,318.54,191.12,,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,38.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,286.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,30.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,37.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.56,286.69,
T&B LYMPHOCYTE CLONAL GENOTYPE PROFILE,1501346,CDM,300,RC,83890,HCPCS,outpatient,,,604.71,362.83,,453.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,453.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,453.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,453.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,453.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,453.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.36,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.91,544.24,
Blood test to evaluate thyroid function,1501426,CDM,300,RC,84480,HCPCS,outpatient,,,21.63,12.98,,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,19.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.48,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.48,19.48,
T3 FREE,1501428,CDM,300,RC,84481,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,93.63,
T3 REVERSE BY RIA,1500177,CDM,300,RC,84482,HCPCS,outpatient,,,193.41,116.05,,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,174.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.76,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.76,174.07,
Blood test to evaluate thyroid function,1502095,CDM,300,RC,84480,HCPCS,outpatient,,,72.68,43.61,,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.48,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.48,65.41,
T3 UPTAKE,1500518,CDM,300,RC,84479,HCPCS,outpatient,,,18.54,11.12,,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,16.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,16.69,
T3 UPTAKE SENDOUT,1502094,CDM,300,RC,84479,HCPCS,outpatient,,,64.2,38.52,,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,57.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.24,57.78,
Blood test to measure a type of thyroid hormone,1501348,CDM,300,RC,84436,HCPCS,outpatient,,,11.33,6.8,,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,10.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.56,10.51,
Blood test to evaluate thyroid function,1501429,CDM,300,RC,84439,HCPCS,outpatient,,,80.53,48.32,,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.31,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.31,72.48,
Test is used to measure the amount of the drug in the blood to determine whether the concentration has reached a therapeutic level and is below the to,1501809,CDM,300,RC,80197,HCPCS,outpatient,,,184.95,110.97,,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,166.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.73,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.12,166.46,
TB GOLD,1502096,CDM,300,RC,86480,HCPCS,outpatient,,,455.39,273.23,,341.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,94.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,94.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,341.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.21,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,409.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,93.9,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,93.9,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,61.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.2,409.85,
TB STAIN (AFB STAIN),1501200,CDM,300,RC,87206,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.49,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.37,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.37,120.23,
TEGRETOL,1500216,CDM,300,RC,80156,HCPCS,outpatient,,,213.63,128.18,,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.86,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,192.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.8,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.8,192.27,
TEICHOIC ACID,1500560,CDM,300,RC,86329,HCPCS,outpatient,,,71.57,42.94,,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.46,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.33,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.39,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.39,64.41,
TESTOSTERONE SEND OUT,1502118,CDM,300,RC,84403,HCPCS,outpatient,,,376.99,226.19,,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.45,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,26.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,339.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.91,339.29,
"TESTOSTERONE, TOTAL",1500169,CDM,300,RC,84403,HCPCS,outpatient,,,112.27,67.36,,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,39.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.45,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,26.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,101.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.91,101.04,
TETANUS,1501715,CDM,300,RC,86774,HCPCS,outpatient,,,174.56,104.74,,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.24,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.09,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,157.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.99,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.99,157.1,
THALLIUM,1502045,CDM,300,RC,83018,HCPCS,outpatient,,,89.6,53.76,,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,80.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.78,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.27,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.78,80.64,
THEOPHYLLINE,1500163,CDM,300,RC,80198,HCPCS,outpatient,,,97.25,58.35,,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.38,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,87.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.46,87.53,
THIAMINE,1501368,CDM,300,RC,84425,HCPCS,outpatient,,,240.12,144.07,,180.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.39,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,180.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,216.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.2,216.11,
THROMBIN TIME,1500501,CDM,300,RC,85670,HCPCS,outpatient,,,95.88,57.53,,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.82,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,86.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.67,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.67,86.29,
THYROGLOBULIN,1501823,CDM,300,RC,84432,HCPCS,outpatient,,,223.74,134.24,,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.54,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,201.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.05,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,201.37,
THYROID PEROXIDASE ANTIBODY,1501822,CDM,300,RC,86376,HCPCS,outpatient,,,364.16,218.5,,273.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,273.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,327.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,273.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,273.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.79,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.79,327.74,
THYROID STIMULATING IMMUNOGLOBULIN (TSI),1501824,CDM,300,RC,84445,HCPCS,outpatient,,,726.67,436,,545,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,545,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,51.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,654,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,545,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,41.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,654,
THYROTROPIN RELEASING HORMONE,1500366,CDM,300,RC,80438,HCPCS,outpatient,,,508.93,305.36,,381.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,407.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,76.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,76.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,381.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,51.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,458.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,381.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,381.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,50.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.83,458.04,
THYROXIN BINDING GLOBULIN,1501357,CDM,300,RC,84442,HCPCS,outpatient,,,96.71,58.03,,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,87.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.97,87.04,
Blood test that measures the amount of iron carried in the blood,1501483,CDM,300,RC,83550,HCPCS,outpatient,,,28.84,17.3,,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.36,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.33,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.33,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.91,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.08,25.96,
TIMOTHY GRASS IGE SPEC ALLERGEN (G6),1501229,CDM,300,RC,8600390,HCPCS,outpatient,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.08,13.52,
TISSUE CULTURE,1500219,CDM,300,RC,88230,HCPCS,outpatient,,,473.96,284.38,,355.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,379.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,151.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,177.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,177.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,355.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,118.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,426.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,355.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,176.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,94.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,176.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.36,426.56,
TISSUE CULTURE,1500372,CDM,300,RC,87252,HCPCS,outpatient,,,100.81,60.49,,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.89,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.72,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.72,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,26.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,90.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.5,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.5,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.11,90.73,
TISSUE CULTURE AMNIONIC FLD,1502417,CDM,300,RC,8823590,HCPCS,outpatient,,,398.9,239.34,,299.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,299.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,359.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,299.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,199.45,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.73,359.01,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1501887,CDM,300,RC,83516,HCPCS,outpatient,,,130.31,78.19,,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,117.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,117.28,
TOBRAMYCIN PEAK,1500155,CDM,300,RC,80200,HCPCS,outpatient,,,166.91,100.15,,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,150.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.07,150.22,
TOBRAMYCIN TROUGH,1501155,CDM,300,RC,80200,HCPCS,outpatient,,,166.64,99.98,,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.85,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,149.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.07,149.98,
TONOCARD LEVEL,1500360,CDM,300,RC,80176,HCPCS,outpatient,,,119.11,71.47,,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,107.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.9,107.2,
TOPAMAX,1501415,CDM,300,RC,80201,HCPCS,outpatient,,,180.3,108.18,,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,162.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.66,162.27,
TOPRIMATE,1501717,CDM,300,RC,80201,HCPCS,outpatient,,,157.08,94.25,,117.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,117.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.21,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,141.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,117.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.66,141.37,
TOTAL BILE ACIDS,1501988,CDM,300,RC,82239,HCPCS,outpatient,,,69.11,41.47,,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.14,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.18,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,62.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.87,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.87,62.2,
TOTAL PROTEIN (SERUM),1500061,CDM,300,RC,84155,HCPCS,outpatient,,,67.75,40.65,,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,60.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.97,60.98,
TOTAL PROTEIN PLEURAL FLUID,1500526,CDM,300,RC,84155,HCPCS,outpatient,,,64.47,38.68,,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,58.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.97,58.02,
TOTAL PROTEIN URINE,1502413,CDM,300,RC,84156,HCPCS,outpatient,,,9.84,5.9,,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,8.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.97,8.86,
TOXOCARA TITRE,1501201,CDM,300,RC,86682,HCPCS,outpatient,,,434.09,260.45,,325.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,325.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,390.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,325.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,325.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.54,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.54,390.68,
TOXOPLASMA ANTIBODIES,1500506,CDM,300,RC,86777,HCPCS,outpatient,,,182.21,109.33,,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,163.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,163.99,
TOXOPLASMOSIS,1500273,CDM,300,RC,86777,HCPCS,outpatient,,,83.05,49.83,,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,74.75,
Testing for presence of drug,1502151,CDM,300,RC,80307,HCPCS,outpatient,,,170.19,102.11,,127.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.78,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,127.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.31,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,63.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,153.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.69,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,62.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.34,153.17,
TRANSFERRIN,1500264,CDM,300,RC,84466,HCPCS,outpatient,,,141.78,85.07,,106.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,127.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.33,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.33,127.6,
Chemical test of the blood to measure presence or concentration of a substance in the blood,1501944,CDM,300,RC,83516,HCPCS,outpatient,,,170.74,102.44,,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,153.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.34,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.53,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.34,153.67,
TRANXENE,1500212,CDM,300,RC,80299,HCPCS,outpatient,,,175.39,105.23,,131.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,131.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,157.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,157.85,
TRAZODONE BLOOD LEVEL (DESYREL),1500472,CDM,300,RC,80338,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.93,315.94,
Blood test to determine existence of certain bacterium that causes syphilis,1501362,CDM,300,RC,86780,HCPCS,outpatient,,,53.82,32.29,,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,13.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,48.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.73,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.73,48.44,
TRICYCLIC ANTIDEPRESSANT QUANT,1501994,CDM,300,RC,80335,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.35,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.12,315.94,
TRIGLYCERIDE (FLUID),1502055,CDM,300,RC,84478,HCPCS,outpatient,,,32.24,19.34,,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.46,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,29.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.65,29.02,
TRIGLYCERIDES,1500081,CDM,300,RC,84478,HCPCS,outpatient,,,112.01,67.21,,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.46,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,100.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.65,100.81,
TRILEPTAL,1502380,CDM,300,RC,80183,HCPCS,outpatient,,,38.24,22.94,,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.51,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,34.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.74,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.74,34.42,
TRIPLE SCREEN,1501462,CDM,300,RC,82105,HCPCS,outpatient,,,252.7,151.62,,189.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,189.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,227.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,189.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.58,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.58,227.43,
TROPHERYMA WHIPPLEI DNA QUAL PCR (11352),1502452,CDM,300,RC,8779890,HCPCS,outpatient,,,175.1,105.06,,131.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,131.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.88,157.59,
Blood test to measure a certain protein in the blood to determine heart muscle damage,1501449,CDM,300,RC,84484,HCPCS,outpatient,,,72.1,43.26,,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.1,64.89,
TRYPSIN,1501848,CDM,300,RC,83519,HCPCS,outpatient,,,219.36,131.62,,164.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,164.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,197.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,164.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,197.42,
TRYPSIN- STOOL,1500299,CDM,300,RC,84490,HCPCS,outpatient,,,85.79,51.47,,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.63,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.05,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.93,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.05,77.21,
TRYPTASE,1502103,CDM,300,RC,83520,HCPCS,outpatient,,,130.58,78.35,,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.45,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,117.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.99,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.99,117.52,
"Blood test, thyroid stimulating hormone (TSH)",1500106,CDM,300,RC,84443,HCPCS,outpatient,,,44.29,26.57,,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.66,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.61,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.61,39.86,
TSH ANTIBODY,1501864,CDM,300,RC,83519,HCPCS,outpatient,,,383.82,230.29,,287.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,287.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,18.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,345.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,287.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.9,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.47,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.9,345.44,
"Blood test, thyroid stimulating hormone (TSH)",1502090,CDM,300,RC,84443,HCPCS,outpatient,,,150.79,90.47,,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.66,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,135.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.61,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.61,135.71,
TSH RECEPTOR ANTIBODIES,1501286,CDM,300,RC,86317,HCPCS,outpatient,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.49,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.3,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,180.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.14,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.14,180.96,
TUBERCULIN (PPD) SKIN TEST,1401761,CDM,300,RC,86580,HCPCS,outpatient,,,33.16,19.9,,24.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,29.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.8,29.84,
TULAREMIA AGGLUTININS,1501294,CDM,300,RC,86000,HCPCS,outpatient,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,25.82,
TYLENOL (ACETAMINOPHEN),1501249,CDM,300,RC,80143,HCPCS,outpatient,,,351.04,210.62,,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.12,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,315.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,263.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.97,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,315.94,
TYPHOID,1500473,CDM,300,RC,86757,HCPCS,outpatient,,,155.17,93.1,,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.54,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.54,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.68,139.65,
TZANK PREP,1501436,CDM,300,RC,88161,HCPCS,outpatient,,,71.57,42.94,,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,42.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.39,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.04,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,64.41,
Manual urinalysis test with examination without using microscope,1501936,CDM,300,RC,81002,HCPCS,outpatient,,,55.62,33.37,,41.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,41.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.82,50.06,
Manual urinalysis test with examination with or without using microscope,1501935,CDM,300,RC,81001,HCPCS,outpatient,,,23.69,14.21,,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,21.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.57,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.57,21.32,
ULTRACENTRIFUGATION,1501883,CDM,300,RC,83701,HCPCS,outpatient,,,106.28,63.77,,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,37.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,34.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,95.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.42,95.65,
UR VOL MEASURMENT TIMED SPEC EA,1502160,CDM,300,RC,81050,HCPCS,outpatient,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,10.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.95,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.95,10.82,
URIC ACID,1500082,CDM,300,RC,84550,HCPCS,outpatient,,,32.96,19.78,,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,29.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.66,29.66,
URIC ACID - URINE,1502058,CDM,300,RC,84560,HCPCS,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.11,25.33,
Automated urinalysis test,1501911,CDM,300,RC,81003,HCPCS,outpatient,,,83.05,49.83,,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.43,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,2.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,1.83,90,,,fee schedule,90% UHC fee schedule for outpatient setting,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.41,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.83,74.75,
URINE AMYLASE 2 HR,1500323,CDM,300,RC,82150,HCPCS,outpatient,,,29.5,17.7,,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,26.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.25,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.25,26.55,
URINE CALCIUM 24 HR,1500324,CDM,300,RC,82340,HCPCS,outpatient,,,37.71,22.63,,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,33.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.89,33.94,
"URINE CALCIUM, QUANT, TIMED SPEC",1502158,CDM,300,RC,82340,HCPCS,outpatient,,,25.13,15.08,,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,22.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.89,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.15,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.89,22.62,
URINE CITRATE,1500509,CDM,300,RC,82507,HCPCS,outpatient,,,360.06,216.04,,270.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,288.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,42.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,270.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.49,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,28.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,324.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,270.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.52,90,,,fee schedule,90% UHC fee schedule for outpatient setting,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.52,324.05,
Test to measure creatinine in the urine,1502159,CDM,300,RC,82570,HCPCS,outpatient,,,21.58,12.95,,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.28,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,19.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.19,19.42,
URINE EOSINOPHILS,1502410,CDM,300,RC,85999,HCPCS,outpatient,,,10.93,6.56,,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,9.84,
URINE FOR HEMOSIDERIN,1501326,CDM,300,RC,83070,HCPCS,outpatient,,,84.69,50.81,,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,76.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.85,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.85,76.22,
URINE FOR MYOGLOBIN,1500145,CDM,300,RC,83874,HCPCS,outpatient,,,104.63,62.78,,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.73,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,94.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.47,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.92,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.47,94.17,
Manual urinalysis test with examination using microscope,1500510,CDM,300,RC,81000,HCPCS,outpatient,,,62.28,37.37,,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.85,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,56.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.26,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.26,56.05,
URINE HEMOGLOBIN,1500507,CDM,300,RC,83069,HCPCS,outpatient,,,93.43,56.06,,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,84.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.2,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.2,84.09,
URINE OXALATES,1500511,CDM,300,RC,83945,HCPCS,outpatient,,,142.33,85.4,,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,128.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.71,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.51,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.45,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.71,128.1,
URINE PHOSPHOROUS,1500512,CDM,300,RC,84105,HCPCS,outpatient,,,68.85,41.31,,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,61.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.68,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.68,61.97,
Urine pregnancy test,1500060,CDM,300,RC,81025,HCPCS,outpatient,,,212.18,127.31,,159.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.19,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,159.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,190.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,190.96,
URINE PROTEIN,1500513,CDM,300,RC,84155,HCPCS,outpatient,,,58.99,35.39,,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,53.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.67,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.97,53.09,
URINE URIC ACID,1500514,CDM,300,RC,84560,HCPCS,outpatient,,,62.01,37.21,,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,55.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.11,55.81,
Manual urinalysis test with examination without using microscope,1500161,CDM,300,RC,81002,HCPCS,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.52,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.9,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.82,92.44,
UROPORPHYRIN,1500515,CDM,300,RC,84120,HCPCS,outpatient,,,174.3,104.58,,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,22.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,156.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.92,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.29,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.71,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.92,156.87,
UTERUS TISSUE-H,1500196,CDM,300,RC,,,outpatient,,,202.43,121.46,,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,182.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.48,182.19,
VALPROATE,1500363,CDM,300,RC,80164,HCPCS,outpatient,,,83.05,49.83,,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.97,74.75,
VANCOMYCIN (PEAK),1500407,CDM,300,RC,80202,HCPCS,outpatient,,,50.47,30.28,,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.97,45.42,
VANCOMYCIN (TROUGH),1501826,CDM,300,RC,80202,HCPCS,outpatient,,,50.47,30.28,,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.31,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.97,45.42,
VARICELLA ZOSTER PCR,1502338,CDM,300,RC,87798,HCPCS,outpatient,,,125.12,75.07,,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.62,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,35.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,112.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.42,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.72,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.42,112.61,
VARICELLA ZOSTER VIRUS AB (IGG/IGM),1501356,CDM,300,RC,86787,HCPCS,outpatient,,,64.47,38.68,,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,19.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,58.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.88,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.43,58.02,
VASOACTIVE INTESTINAL POLYPEPTIDE TITER,1501712,CDM,300,RC,84586,HCPCS,outpatient,,,143.15,85.89,,107.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,107.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,36.03,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,128.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,107.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,28.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.62,128.84,
Blood test to screen for syphilis,1501439,CDM,300,RC,86592,HCPCS,outpatient,,,31.15,18.69,,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.65,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,28.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,28.04,
Collection of venous blood by venipuncture,1500533,CDM,300,RC,36415,HCPCS,outpatient,,,75.19,45.11,,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.43,67.67,
Collection of venous blood by venipuncture,1501703,CDM,300,RC,36415,HCPCS,outpatient,,,75.19,45.11,,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,67.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.43,67.67,
Collection of venous blood by venipuncture,2500062,CDM,300,RC,36415,HCPCS,outpatient,,,25.36,15.22,,19.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,22.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,19.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.43,22.82,
VERAPAMIL,1501365,CDM,300,RC,80299,HCPCS,outpatient,,,125.94,75.56,,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,113.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,113.35,
VIRAL STUDIES,1500240,CDM,300,RC,87253,HCPCS,outpatient,,,125.12,75.07,,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.26,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.84,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.6,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,112.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.68,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.36,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.68,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.36,112.61,
VITAMIN A,1500516,CDM,300,RC,84590,HCPCS,outpatient,,,180.02,108.01,,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.71,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,162.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.41,162.02,
VITAMIN B3 (91029),1502489,CDM,300,RC,8459190,HCPCS,outpatient,,,45.32,27.19,,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.66,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.29,40.79,
VITAMIN C,1501343,CDM,300,RC,82180,HCPCS,outpatient,,,73.21,43.93,,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,10.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.01,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.01,65.89,
"VITAMIN D (1,25 DIHYDROXY)",1501989,CDM,300,RC,82652,HCPCS,outpatient,,,50.47,30.28,,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,58.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,58.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.81,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,39.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,31.19,90,,,fee schedule,90% UHC fee schedule for outpatient setting,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.32,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.19,58.81,
Blood test to monitor vitamin D levels,1501886,CDM,300,RC,82306,HCPCS,outpatient,,,66.95,40.17,,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,45.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.19,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,60.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.98,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.6,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.98,60.26,
VITAMIN E,1502135,CDM,300,RC,84446,HCPCS,outpatient,,,57.37,34.42,,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.66,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,51.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.48,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.18,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.48,51.63,
VITAMIN K,1501205,CDM,300,RC,84597,HCPCS,outpatient,,,56.28,33.77,,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,13.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.12,90,,,fee schedule,90% UHC fee schedule for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.12,50.65,
VMA,1500141,CDM,300,RC,84585,HCPCS,outpatient,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.15,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.64,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.68,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,15.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,180.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.48,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.56,180.96,
VON WILLEBRAND MULTIMETRIC ANALYSIS,1501317,CDM,300,RC,85247,HCPCS,outpatient,,,511.67,307,,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,460.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.59,460.5,
VON WILLEBRAND(VIII)FACTOR ANTIGEN,1501981,CDM,300,RC,85246,HCPCS,outpatient,,,511.67,307,,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,460.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.59,460.5,
VON WILLEBRAND(VIII)RISTOCETIN COFACTOR,1501980,CDM,300,RC,85245,HCPCS,outpatient,,,511.67,307,,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,23.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,460.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.59,90,,,fee schedule,90% UHC fee schedule for outpatient setting,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.59,460.5,
WBC,1500084,CDM,300,RC,85048,HCPCS,outpatient,,,56,33.6,,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,2.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.06,90,,,fee schedule,90% UHC fee schedule for outpatient setting,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.06,50.4,
Blood test to assess for infection,1500085,CDM,300,RC,85007,HCPCS,outpatient,,,76.77,46.06,,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.94,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,69.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.08,69.09,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,1500393,CDM,300,RC,87205,HCPCS,outpatient,,,18.54,11.12,,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,16.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,16.69,
WEIL-FELIX,1500289,CDM,300,RC,86000,HCPCS,outpatient,,,68.02,40.81,,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.07,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.65,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.11,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,61.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.98,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.65,61.22,
WEST NILE AB,1502342,CDM,300,RC,86789,HCPCS,outpatient,,,112.55,67.53,,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.71,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.67,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,101.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.66,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.63,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.66,101.3,
WEST NILE ABS IGM,1502341,CDM,300,RC,86788,HCPCS,outpatient,,,112.55,67.53,,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,101.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.65,101.3,
WEST NILE VIRUS ANTIBODIES,1501711,CDM,300,RC,86788,HCPCS,outpatient,,,526.69,316.01,,395.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,421.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25.7,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,395.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.75,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,474.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,395.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,395.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.65,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.65,474.02,
WESTERN EQUINE ENCEPHALITIS IGG,1502432,CDM,300,RC,8665490,HCPCS,outpatient,,,43.5,26.1,,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,39.15,
WESTERN EQUINE ENCEPHALITIS IGM,1502433,CDM,300,RC,8665490,HCPCS,outpatient,,,43.5,26.1,,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.91,39.15,
A lab test to screen for evidence of vaginal infection,1500049,CDM,300,RC,87210,HCPCS,outpatient,,,72.4,43.44,,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.93,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,65.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.72,90,,,fee schedule,90% UHC fee schedule for outpatient setting,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.72,65.16,
WET PREP,1500520,CDM,300,RC,87220,HCPCS,outpatient,,,31.96,19.18,,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,28.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,28.76,
XANAX,1500355,CDM,300,RC,80299,HCPCS,outpatient,,,373.71,224.23,,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,336.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,336.34,
ZARONTIN-ETHSUXIMIDE,1500316,CDM,300,RC,80168,HCPCS,outpatient,,,105.17,63.1,,78.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.24,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,24.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,78.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,94.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.24,94.65,
ZINC,1500184,CDM,300,RC,84630,HCPCS,outpatient,,,127.03,76.22,,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.81,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,114.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.23,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.23,114.33,
ZINC PROTOPORPHYRIN,1500338,CDM,300,RC,84202,HCPCS,outpatient,,,127.85,76.71,,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.93,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,14.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,115.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.63,90,,,fee schedule,90% UHC fee schedule for outpatient setting,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.63,115.07,
ZINC TRANSPORTER 8 ANTIBODY (93022),1502492,CDM,300,RC,8634190,HCPCS,outpatient,,,64.3,38.58,,48.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,48.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.15,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.18,57.87,
ZOLOFT,1501369,CDM,300,RC,80299,HCPCS,outpatient,,,211.98,127.19,,158.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.36,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,158.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.4,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,19.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,190.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,158.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.1,90,,,fee schedule,90% UHC fee schedule for outpatient setting,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.1,190.78,
".6TGN, 6MP LEVEL",1502029,CDM,301,RC,82491,HCPCS,outpatient,,,456.22,273.73,,342.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,364.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,342.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,410.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,342.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,228.11,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.48,410.6,
Test to measure arterial blood gases,2600028,CDM,301,RC,82803,HCPCS,outpatient,,,130.31,78.19,,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.89,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,26.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,117.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.11,117.28,
Test to measure arterial blood gases,2600029,CDM,301,RC,82803,HCPCS,outpatient,,,39.14,23.48,,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.89,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,26.59,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,35.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.11,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.07,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.11,35.23,
CHROMOGRANIN A,1502030,CDM,301,RC,86316,HCPCS,outpatient,,,121.57,72.94,,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.05,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.73,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,21.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,109.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.86,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.52,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.86,109.41,
FACTOR V LEIDEN BY PCR,1502032,CDM,301,RC,81241,HCPCS,outpatient,,,697.16,418.3,,522.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,557.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.38,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,522.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,74.83,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,627.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,522.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,522.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,522.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,522.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,59.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,73.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,627.44,
GASES BLOOD PH ONLY,2600087,CDM,301,RC,82800,HCPCS,outpatient,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.94,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,11.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,43.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.91,90,,,fee schedule,90% UHC fee schedule for outpatient setting,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.83,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.91,43.52,
HEALTH CHECK REL INTERPERIODIC ONE,298002,CDM,301,RC,Y5352,HCPCS,outpatient,,,259.8,155.88,,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,233.82,
HEALTH CHECK REL INTERPERIODIC TWO,298003,CDM,301,RC,Y5353,HCPCS,outpatient,,,259.8,155.88,,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129.9,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,233.82,
IN AND OUT SPECIMEN COLLECTION,1750017,CDM,301,RC,P9612,HCPCS,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.43,39.58,
IN and OUT SPECIMEN COLLECTION,2500077,CDM,301,RC,P9612,HCPCS,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.43,90,,,fee schedule,90% UHC fee schedule for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.43,12.05,
POSTPARTUM HOME VISIT ONE,298000,CDM,301,RC,Y5350,HCPCS,outpatient,,,339.02,203.41,,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,305.12,
POSTPARTUM HOME VISIT TWO,298001,CDM,301,RC,Y5351,HCPCS,outpatient,,,339.02,203.41,,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.47,305.12,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,1500198,CDM,310,RC,87205,HCPCS,outpatient,,,42.34,25.4,,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.55,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.58,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.58,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,4.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,38.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.46,90,,,fee schedule,90% UHC fee schedule for outpatient setting,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.46,38.11,
APOE 4,1501392,CDM,310,RC,81401,HCPCS,outpatient,,,534.34,320.6,,400.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,178.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,135.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,135.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,400.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,139.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,480.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,400.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,400.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,134.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,110.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,134.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,110.97,480.91,
BNE MARRW ASPIRATN-H,1500188,CDM,310,RC,,,outpatient,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,180.96,
BNE MARRW READING-H,1500189,CDM,310,RC,,,outpatient,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,180.96,
BONE DECALCIFICATION,1500434,CDM,310,RC,88311,HCPCS,outpatient,,,19.39,11.63,,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.31,90,,,fee schedule,90% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.62,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.31,18.77,
BONE MARROW SMEARS/BIOPSY,1500424,CDM,310,RC,85097,HCPCS,outpatient,,,48.64,29.18,,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,887.9,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,696.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,43.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,508.84,90,,,fee schedule,90% UHC fee schedule for outpatient setting,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.48,887.9,
CONS. SUR FRZ SEC AD,1500423,CDM,310,RC,88332,HCPCS,outpatient,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,45.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.71,90,,,fee schedule,90% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.71,45.6,
CONS. SURG FROZ SECT,1500429,CDM,310,RC,88331,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,90.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,90.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.83,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,90.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,90.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,90.08,235.29,
CYTOLOGY - PLEURAL FLUID,1500425,CDM,310,RC,88104,HCPCS,outpatient,,,186.58,111.95,,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,167.92,
CYTOLOGY INPAT-H,1500192,CDM,310,RC,88104,HCPCS,outpatient,,,127.31,76.39,,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,114.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,114.58,
CYTOLOGY MISCELLANEOUS,1501986,CDM,310,RC,88104,HCPCS,outpatient,,,186.58,111.95,,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,167.92,
CYTOLOGY OUTPAT-H,1500193,CDM,310,RC,,,outpatient,,,65.56,39.34,,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.43,59,
CYTOLOGY-FNA,1500431,CDM,310,RC,88173,HCPCS,outpatient,,,100.26,60.16,,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,111.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,111.09,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.27,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,90.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,110.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,110.34,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.07,111.27,
CYTOLOGY-MISC,1501744,CDM,310,RC,88104,HCPCS,outpatient,,,186.58,111.95,,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,167.92,
CYTOLOGY-PAP INPT-H,1500194,CDM,310,RC,,,outpatient,,,72.12,43.27,,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.78,64.91,
CYTOLOGY-PAP OUTPT-H,1500195,CDM,310,RC,,,outpatient,,,60.1,36.06,,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.31,54.09,
CYTOLOGY-PARACENTESIS(PERITONEAL/ACITES),1501983,CDM,310,RC,88104,HCPCS,outpatient,,,186.58,111.95,,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,167.92,
CYTOLOGY-SPUTUM,1501984,CDM,310,RC,88104,HCPCS,outpatient,,,186.58,111.95,,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,167.92,
CYTOLOGY-THORACENTESIS (PLEURAL FLUID),1501739,CDM,310,RC,88104,HCPCS,outpatient,,,186.58,111.95,,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,167.92,
CYTOLOGY-URINE,1501985,CDM,310,RC,88104,HCPCS,outpatient,,,186.58,111.95,,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,51.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.43,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,167.92,
CYTOPATH EVAL OF FINE NEEDLE ASP,1502164,CDM,310,RC,88172,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,68.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.74,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,68.17,417.97,
CYTOPATHOLOGY ANY OTHER SOURCE,1502337,CDM,310,RC,88160,HCPCS,outpatient,,,46.44,27.86,,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,41.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,56.05,
FIRST MIS TISSUE-I-H,1500197,CDM,310,RC,,,outpatient,,,161.18,96.71,,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,101.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.03,145.06,
FROZ SECT TISSUE-H,1500190,CDM,310,RC,,,outpatient,,,444.47,266.68,,333.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,333.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,400.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,333.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,280.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.07,400.02,
HEMOCHROMATOSIS MUTATION DETECTION,1501469,CDM,310,RC,81256,HCPCS,outpatient,,,536.29,321.77,,402.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,84.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,48.52,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,402.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,66.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,482.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,402.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,402.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,52.94,90,,,fee schedule,90% UHC fee schedule for outpatient setting,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,65.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.2,482.66,
HPV FROM THIN PREP,1501982,CDM,310,RC,88365,HCPCS,outpatient,,,261.43,156.86,,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,106.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,106.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,106.25,235.29,
MA TUMR HER-2/NEU ER/PR RECP EA AB SNGL,1501523,CDM,310,RC,88360,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,118.45,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,118.45,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.64,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,117.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,117.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.24,217.1,
MISC TISSUE-OUTPT-H,1500199,CDM,310,RC,,,outpatient,,,68.3,40.98,,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,43.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.99,61.47,
MORPHOMETRIC ANALYSIS MULTIPLEX STAIN,1502388,CDM,310,RC,88377,HCPCS,outpatient,,,139.33,83.6,,104.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,220.33,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,220.33,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,104.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,220.69,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,125.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,104.5,220.69,
Urine test,1502111,CDM,310,RC,88112,HCPCS,outpatient,,,113.92,68.35,,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,128.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,128.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,102.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.07,129.02,
PAP smear,1502022,CDM,310,RC,88175,HCPCS,outpatient,,,107.37,64.42,,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,26.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,40.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,40.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.44,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,27.14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,96.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,26.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.56,96.63,
PAP smear,1501977,CDM,310,RC,88142,HCPCS,outpatient,,,82.5,49.5,,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,20.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.41,90,,,fee schedule,90% UHC fee schedule for outpatient setting,20.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.7,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.41,74.25,
PAP TEST RIA,1500164,CDM,310,RC,84066,HCPCS,outpatient,,,124.57,74.74,,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.56,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.74,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.76,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,9.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,112.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.82,90,,,fee schedule,90% UHC fee schedule for outpatient setting,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.66,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.82,112.11,
Blood test to assist with diagnosis,1501742,CDM,310,RC,88312,HCPCS,outpatient,,,165.55,99.33,,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,52.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,149,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.07,149,
Pathology test,1501947,CDM,310,RC,88342,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,86.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,86.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,116.24,90,,,fee schedule,90% UHC fee schedule for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.25,417.97,
Blood test to assist with diagnosis,1500427,CDM,310,RC,88312,HCPCS,outpatient,,,63.86,38.32,,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,52.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.63,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.72,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,57.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.07,57.47,
SPECIAL STAIN H,1500201,CDM,310,RC,,,outpatient,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,126.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,180.96,
Blood test to assist with diagnosis,1500428,CDM,310,RC,88313,HCPCS,outpatient,,,91.52,54.91,,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,54.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,82.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,82.37,
Test of tissues for diagnosis of abnormalities,1500416,CDM,310,RC,88305,HCPCS,outpatient,,,63.86,38.32,,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,79.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,57.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.38,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.38,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.07,80.04,
SUR PATH COMP/DIAGN,1500422,CDM,310,RC,88309,HCPCS,outpatient,,,1145.17,687.1,,858.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,916.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,887.9,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,227.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,227.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,858.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,696.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1030.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,858.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,858.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,858.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,858.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,226.26,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,508.84,90,,,fee schedule,90% UHC fee schedule for outpatient setting,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,226.26,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,683,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,226.26,1030.65,
SUR PATH GRS MIC UNC,1500419,CDM,310,RC,88304,HCPCS,outpatient,,,198.06,118.84,,148.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,36.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,148.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.67,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,178.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.36,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.36,178.25,
SUR PATH SING DISSEC,1500421,CDM,310,RC,88307,HCPCS,outpatient,,,464.41,278.65,,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,371.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,161.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,161.69,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.96,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,417.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,229.56,90,,,fee schedule,90% UHC fee schedule for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.61,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.61,417.97,
Test of tissues for diagnosis of abnormalities,1500420,CDM,310,RC,88305,HCPCS,outpatient,,,237.13,142.28,,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,57.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,79.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.91,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,44.98,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,213.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.38,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.07,90,,,fee schedule,90% UHC fee schedule for outpatient setting,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.38,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,44.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.07,213.42,
SURG PATH GRS & MICR,1500418,CDM,310,RC,88302,HCPCS,outpatient,,,158.17,94.9,,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,42.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,142.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.62,142.35,
SURG. PATH. GROSS,1500417,CDM,310,RC,88300,HCPCS,outpatient,,,71.57,42.94,,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.35,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.37,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,22.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.62,90,,,fee schedule,90% UHC fee schedule for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.23,64.41,
THIOPURINE METHYL TRANSFERASE,1502031,CDM,310,RC,81401,HCPCS,outpatient,,,655.36,393.22,,491.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.29,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,178.1,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,135.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,135.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,491.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,139.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,589.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,491.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,134.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,110.97,90,,,fee schedule,90% UHC fee schedule for outpatient setting,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,134.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,137,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,110.97,589.82,
CYTOPATHOLOGY CONC TECHNIQUE,1501771,CDM,311,RC,88108,HCPCS,outpatient,,,71.57,42.94,,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.08,90,,,fee schedule,90% UHC fee schedule for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.08,64.41,
PAP CYTOPATH CERV/VAG,1502420,CDM,311,RC,8814290,HCPCS,outpatient,,,63.65,38.19,,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.04,57.29,
Cervical cancer screening test done manually,1501748,CDM,311,RC,88150,HCPCS,outpatient,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,43.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.25,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.25,43.52,
Cervical cancer screening test done manually,1500426,CDM,311,RC,88150,HCPCS,outpatient,,,48.36,29.02,,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.5,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,43.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.25,90,,,fee schedule,90% UHC fee schedule for outpatient setting,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.25,43.52,
Serial radiologic examination of the abdomen,1600002,CDM,320,RC,74022,HCPCS,outpatient,,,154.5,92.7,,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.66,286.93,
ABDOMEN- 2 VIEWS (FT & UPRT OR DECUB),1600003,CDM,320,RC,74019,HCPCS,outpatient,,,140.08,84.05,,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,286.93,
ABDOMEN-FLAT-KUB,1600001,CDM,320,RC,74018,HCPCS,outpatient,,,434.66,260.8,,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,92.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,391.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,391.19,
ACROMIO-CLAVIC.JTS BILAT W/ OR W/O WTS,1600005,CDM,320,RC,73050,HCPCS,outpatient,,,160.63,96.38,,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.91,204.32,
ANKLE 2 VIEW BILAT,1600181,CDM,320,RC,7360050,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,337.08,
ANKLE BILAT 3+ VIEWS,1600301,CDM,320,RC,7361050,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,337.08,
ANKLE LT 2 VIEWS,1600691,CDM,320,RC,73600LT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
ANKLE LT ROUTINE 3+ VIEWS,1600551,CDM,320,RC,73610LT,HCPCS,outpatient,,,423.33,254,,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,381,
ANKLE RT 2 VIEWS,1600672,CDM,320,RC,73600RT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
ANKLE RT ROUTINE 3+ VIEWS,1600006,CDM,320,RC,73610RT,HCPCS,outpatient,,,423.33,254,,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,381,
BA SWALLOW,1600061,CDM,320,RC,74230,HCPCS,outpatient,,,321.54,192.92,,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,289.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,466.48,
BE,1600059,CDM,320,RC,74270,HCPCS,outpatient,,,482.16,289.3,,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,433.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.79,466.48,
"Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema",1600070,CDM,320,RC,G0120,HCPCS,outpatient,,,1134.52,680.71,,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,907.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1021.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,1021.07,
BE W/ AIR CONTRAST,1600060,CDM,320,RC,74280,HCPCS,outpatient,,,584.61,350.77,,438.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,124.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,438.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,526.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,438.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.79,526.15,
BONE AGE,1600081,CDM,320,RC,77072,HCPCS,outpatient,,,284.1,170.46,,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,255.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,286.93,
BONE SURVEY COMPLETE (METS),1600008,CDM,320,RC,77075,HCPCS,outpatient,,,868.18,520.91,,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,184.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,184.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,781.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,177.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,177.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,781.36,
BONE SURVEY LIMITED (METS),1600533,CDM,320,RC,77074,HCPCS,outpatient,,,562.75,337.65,,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,506.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,506.48,
"Radiologic examination of the neck/spine, 4-5 views",1600677,CDM,320,RC,72050,HCPCS,outpatient,,,204.97,122.98,,153.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,43.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,184.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,153.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42,286.93,
CERVICAL SPINE 6+ VIEWS,1600046,CDM,320,RC,72052,HCPCS,outpatient,,,482.16,289.3,,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,433.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,433.94,
"Radiologic examination of the neck/spine, 2-3 views",1600045,CDM,320,RC,72040,HCPCS,outpatient,,,726.15,435.69,,544.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,154.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,544.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,653.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,544.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,653.54,
CLAVICLE LEFT,1600553,CDM,320,RC,73000LT,HCPCS,outpatient,,,160.09,96.05,,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,144.08,
CLAVICLE RT,1600017,CDM,320,RC,73000RT,HCPCS,outpatient,,,160.09,96.05,,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,144.08,
CLAVICLES BILATERAL,1600317,CDM,320,RC,7300050,HCPCS,outpatient,,,320.17,192.1,,240.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,288.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,240.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,240.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,160.09,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.6,288.15,
CLIN DECISION MECH AIM SPC HLTH,1620091,CDM,320,RC,G1007,HCPCS,outpatient,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
COCCYX,1600016,CDM,320,RC,72220,HCPCS,outpatient,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,260.37,
CYSTO-RETROGRADE,1600071,CDM,320,RC,74420,HCPCS,outpatient,,,1134.52,680.71,,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,907.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1021.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,1021.07,
CYSTOGRAM,1600084,CDM,320,RC,74430,HCPCS,outpatient,,,725.85,435.51,,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,154.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,653.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,977.54,
Scan to measure bone mineral density (BMD) at the spine and hip,1600063,CDM,320,RC,77080,HCPCS,outpatient,,,615.94,369.56,,461.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,492.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,131.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,461.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,554.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,461.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,461.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,126.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,126.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,554.35,
DNU*******DEXA SCREENING,1600534,CDM,320,RC,G0130,HCPCS,outpatient,,,427.81,256.69,,320.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.25,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,91.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,320.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,385.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,320.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.66,385.03,
ELBOW BILAT 2 VIEWS,1600066,CDM,320,RC,7307050,HCPCS,outpatient,,,204.62,122.77,,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,184.16,
ELBOW BILAT 3+ VIEWS,1600302,CDM,320,RC,7308050,HCPCS,outpatient,,,301.59,180.95,,226.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,226.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,226.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,150.8,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.8,271.43,
ELBOW LT 2 VIEWS,1600684,CDM,320,RC,73070LT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
ELBOW LT ROUTINE 3+ VIEWS,1600552,CDM,320,RC,73080LT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
ELBOW RT 2 VIEWS,1600668,CDM,320,RC,73070RT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
ELBOW RT ROUTINE 3+ VIEWS,1600018,CDM,320,RC,73080RT,HCPCS,outpatient,,,181.12,108.67,,135.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,135.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.56,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.11,163.01,
FACIAL BONES 3+ VIEWS,1600019,CDM,320,RC,70150,HCPCS,outpatient,,,325.63,195.38,,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,293.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.72,293.07,
FACIAL BONES LIMITED LESS THAN 3 VIEWS,1600664,CDM,320,RC,70140,HCPCS,outpatient,,,242.31,145.39,,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,218.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.65,218.08,
FEMUR BILAT 1 VIEW,1600757,CDM,320,RC,7355150,HCPCS,outpatient,,,173.2,103.92,,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,155.88,
FEMUR BILAT 2 VIEWS EACH,1600303,CDM,320,RC,7355250,HCPCS,outpatient,,,414.42,248.65,,310.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,310.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,372.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,310.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,207.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.91,372.98,
FEMUR LT 1 VIEW,1600758,CDM,320,RC,73551LT,HCPCS,outpatient,,,173.2,103.92,,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,155.88,
FEMUR LT 2+ VIEWS,1600554,CDM,320,RC,73552LT,HCPCS,outpatient,,,109.18,65.51,,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,98.26,
FEMUR RT 1 VIEW,1600759,CDM,320,RC,73551RT,HCPCS,outpatient,,,173.2,103.92,,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.6,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.49,155.88,
FEMUR RT 2+ VIEWS,1600020,CDM,320,RC,73552RT,HCPCS,outpatient,,,213.09,127.85,,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,191.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,159.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,106.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.66,191.78,
FINGER BILAT 2+ VIEWS,1600304,CDM,320,RC,7314050,HCPCS,outpatient,,,283.29,169.97,,212.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,254.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,141.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.05,254.96,
FINGER(S) LT 2+ VIEWS,1600555,CDM,320,RC,73140LT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
FINGER(S) RT 2+ VIEWS,1600021,CDM,320,RC,73140RT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
FLUORO GUIDANCE FOR NEEDLE PLACEMENT,1600402,CDM,320,RC,77002,HCPCS,outpatient,,,225.11,135.07,,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,202.6,
FLUORO GUIDANCE OF NEEDLE OR CATHETER,1600064,CDM,320,RC,77003,HCPCS,outpatient,,,197.78,118.67,,148.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.53,178,
FLUORO MORE THAN ONE HOUR,1600087,CDM,320,RC,76001,HCPCS,outpatient,,,233.03,139.82,,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.52,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.75,209.73,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",1600093,CDM,320,RC,76000,HCPCS,outpatient,,,296.64,177.98,,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,63.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,266.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.78,596.58,
FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS,1600699,CDM,320,RC,77001,HCPCS,outpatient,,,225.11,135.07,,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.13,202.6,
FOOT 2 VIEW BILAT,1600182,CDM,320,RC,7362050,HCPCS,outpatient,,,204.62,122.77,,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,184.16,
FOOT BILATERAL,1600305,CDM,320,RC,7363050,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,337.08,
FOOT LEFT ROUTINE 3 VIEWS,1600556,CDM,320,RC,73630LT,HCPCS,outpatient,,,423.33,254,,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,381,
FOOT LT 2 VIEWS,1600693,CDM,320,RC,73620LT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
FOOT RT 2 VIEWS,1600692,CDM,320,RC,73620RT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
FOOT RT ROUTINE 3+ VIEWS,1600090,CDM,320,RC,73630RT,HCPCS,outpatient,,,423.33,254,,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,381,
FOREARM BILAT,1600306,CDM,320,RC,7309050,HCPCS,outpatient,,,303.23,181.94,,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,272.91,
FOREARM LT,1600557,CDM,320,RC,73090LT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
FOREARM RT,1600022,CDM,320,RC,73090RT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
FOREIGN BODY SINGLE VIEW CHILD,1600009,CDM,320,RC,76010,HCPCS,outpatient,,,234.12,140.47,,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,210.71,
GB (CHOLECYSTOGRAM),1600062,CDM,320,RC,74290,HCPCS,outpatient,,,298.04,178.82,,223.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,63.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,268.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,223.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,223.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,61.07,466.48,
GI W/ KUB (UPPER GI),1600065,CDM,320,RC,74240,HCPCS,outpatient,,,434.91,260.95,,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,92.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,391.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.11,466.48,
GI W/SMALL BOWEL,1600532,CDM,320,RC,74240,HCPCS,outpatient,,,569.59,341.75,,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,121.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,512.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.71,512.63,
GI WITH AIR (UPPER GI),1600145,CDM,320,RC,74246,HCPCS,outpatient,,,453.48,272.09,,340.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,362.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,96.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,408.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,340.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.92,466.48,
GI WITH AIR & SMALL BOWEL,1600074,CDM,320,RC,74246,HCPCS,outpatient,,,595.54,357.32,,446.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,126.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,446.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,535.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,446.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.03,535.99,
HAND 2VIEW BILAT,1600069,CDM,320,RC,7312050,HCPCS,outpatient,,,284.1,170.46,,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.21,255.69,
HAND BILAT 3+ VIEWS,1600307,CDM,320,RC,7313050,HCPCS,outpatient,,,303.23,181.94,,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,272.91,
HAND LT 2 VIEWS,1600687,CDM,320,RC,73120LT,HCPCS,outpatient,,,284.1,170.46,,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,255.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,142.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.21,255.69,
HAND LT ROUTINE 3+ VIEWS,1600558,CDM,320,RC,73130LT,HCPCS,outpatient,,,423.33,254,,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,381,
HAND RT 2 VIEWS,1600670,CDM,320,RC,73120RT,HCPCS,outpatient,,,145.23,87.14,,108.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,72.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.76,130.71,
HAND RT ROUTINE 3+ VIEWS,1600023,CDM,320,RC,73130RT,HCPCS,outpatient,,,423.33,254,,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.67,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.74,381,
HEEL BILAT,1600308,CDM,320,RC,7365050,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,337.08,
HEEL LEFT,1600559,CDM,320,RC,73650LT,HCPCS,outpatient,,,160.09,96.05,,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,144.08,
HEEL RT,1600026,CDM,320,RC,73650RT,HCPCS,outpatient,,,160.09,96.05,,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.05,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.8,144.08,
HIP BILAT WITH PELVIS 2 VIEWS,1600309,CDM,320,RC,73521,HCPCS,outpatient,,,289.43,173.66,,217.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,217.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,217.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.3,286.93,
HIP BILAT WITH PELVIS 3-4 VIEWS,1600756,CDM,320,RC,73522,HCPCS,outpatient,,,361.53,216.92,,271.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,77.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,325.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,271.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.08,325.38,
HIP LT 1 VIEW,1600560,CDM,320,RC,73501LT,HCPCS,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,143.83,
HIP LT ROUTINE UNILAT W/ PELVIS 2-3 VIEW,1600562,CDM,320,RC,73502LT,HCPCS,outpatient,,,147.29,88.37,,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,132.56,
HIP RT ONE VIEW,1600024,CDM,320,RC,73501RT,HCPCS,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,143.83,
HIP RT ROUTINE UNILAT W/ PELVIS 2-3 VIEW,1600025,CDM,320,RC,73502RT,HCPCS,outpatient,,,147.29,88.37,,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.18,132.56,
HUMERUS BILATERAL,1600310,CDM,320,RC,7306050,HCPCS,outpatient,,,339.29,203.57,,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.52,305.36,
HUMERUS LEFT,1600563,CDM,320,RC,73060LT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
HUMERUS RT,1600007,CDM,320,RC,73060RT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
HYSTEROSALPINGOGRAM,1600080,CDM,320,RC,74740,HCPCS,outpatient,,,634.34,380.6,,475.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,507.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,135.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,475.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,570.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,475.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,129.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,129.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,129.98,596.58,
INFUSION IVP,1600088,CDM,320,RC,74410,HCPCS,outpatient,,,569.59,341.75,,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,121.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,512.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,427.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.71,512.63,
IVP,1600068,CDM,320,RC,74400,HCPCS,outpatient,,,725.85,435.51,,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,154.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,653.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,653.27,
JOINT SURVEY 2 OR MORE JTS INC(INFANTS),1620083,CDM,320,RC,77076,HCPCS,outpatient,,,470.42,282.25,,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,100.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,423.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,423.38,
KNEE 1 OR 2 VIEW BILAT,1600566,CDM,320,RC,7356050,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,337.08,
KNEE BILAT 4+ VIEWS,1600180,CDM,320,RC,7356450,HCPCS,outpatient,,,413.05,247.83,,309.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,330.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,309.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,371.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,309.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,206.53,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.63,371.75,
Radiologic examination of both knees,1600761,CDM,320,RC,73565,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,337.08,
KNEE BILATERAL 3 VIEWS,1600311,CDM,320,RC,7356250,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
KNEE LT 1 OR 2 VIEWS,1600688,CDM,320,RC,73560LT,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,337.08,
KNEE LT 3 VIEWS,1600564,CDM,320,RC,73562LT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
KNEE LT ROUTINE 4+ VIEWS,1600689,CDM,320,RC,73564LT,HCPCS,outpatient,,,348.14,208.88,,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,174.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.33,313.33,
KNEE RT 1 OR 2 VIEWS,1600671,CDM,320,RC,73560RT,HCPCS,outpatient,,,374.53,224.72,,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,337.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.27,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.74,337.08,
KNEE RT 3 VIEWS,1600027,CDM,320,RC,73562RT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
KNEE RT ROUTINE 4+ VIEWS,1600175,CDM,320,RC,73564RT,HCPCS,outpatient,,,348.14,208.88,,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,278.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,174.07,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.33,313.33,
KUB PORTABLE,1600091,CDM,320,RC,74018,HCPCS,outpatient,,,434.66,260.8,,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,92.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,391.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,391.19,
LOWER EXT-INFANT-2+ VIEWS BILAT,1600690,CDM,320,RC,7359250,HCPCS,outpatient,,,141.74,85.04,,106.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,106.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,70.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.04,127.57,
LOWER EXTREMITY INFANT 2+ VIEWS LEFT,1620080,CDM,320,RC,73592,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.18,204.32,
LOWER EXTREMITY INFANT 2+ VIEWS RIGHT,1620079,CDM,320,RC,73592,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.18,204.32,
LOWER LEG BILAT,1600312,CDM,320,RC,7359050,HCPCS,outpatient,,,339.29,203.57,,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,169.65,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.52,305.36,
LOWER LEG LT,1600565,CDM,320,RC,73590LT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
LOWER LEG RT,1600029,CDM,320,RC,73590RT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
"X-ray of lower and sacral spine, minimum of 4 views",1600049,CDM,320,RC,72110,HCPCS,outpatient,,,401.84,241.1,,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,85.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,361.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.34,361.66,
LUMBARSACRAL SPINE BENDING VIEWS ONLY,1600682,CDM,320,RC,72120,HCPCS,outpatient,,,322.36,193.42,,241.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,290.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.05,290.12,
LUMBARSACRAL SPINE COMPLETE W/ FLEX/EXT,1600666,CDM,320,RC,72114,HCPCS,outpatient,,,388.47,233.08,,291.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,310.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,82.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,291.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,349.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,291.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,79.6,349.62,
X-ray of the lower spine 2-3 views,1600048,CDM,320,RC,72100,HCPCS,outpatient,,,793.1,475.86,,594.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,168.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,168.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,594.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,170.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,713.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,594.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,594.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,594.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,594.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,713.79,
MANDIBLE COMPLETE 4+ VIEWS,1600030,CDM,320,RC,70110,HCPCS,outpatient,,,324.82,194.89,,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,292.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,292.34,
MANDIBLE PARTIAL LESS THAN 4 VIEWS,1600663,CDM,320,RC,70100,HCPCS,outpatient,,,184.95,110.97,,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,166.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.9,204.32,
MASTOIDS BILAT 3+ VIEWS PER SIDE,1600031,CDM,320,RC,70130,HCPCS,outpatient,,,324.82,194.89,,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,292.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,292.34,
MASTOIDS BILAT LESS THAN 3 VIEWS PER SID,1600674,CDM,320,RC,70120,HCPCS,outpatient,,,284.1,170.46,,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,255.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,286.93,
MM BREAST SPECIMEN SURGERY,1600166,CDM,320,RC,76098,HCPCS,outpatient,,,1134.52,680.71,,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,907.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,575.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,451.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1021.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1232.85,160,,,fee schedule,160% UHC fee schedule for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,1232.85,
MM DUCTOGRAM,1600501,CDM,320,RC,77053,HCPCS,outpatient,,,602.36,361.42,,451.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,481.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,128.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,451.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,542.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,451.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.42,596.58,
NASAL BONES 3+ VIEWS,1600032,CDM,320,RC,70160,HCPCS,outpatient,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,260.37,
NM GI BLEED SCAN,1600176,CDM,320,RC,78278,HCPCS,outpatient,,,1355.8,813.48,,1016.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1084.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,288.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,288.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1016.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1220.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1016.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1016.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1016.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1016.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,277.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,942.42,160,,,fee schedule,160% UHC fee schedule for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,277.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,277.8,1220.22,
OR CHOLANGIOGRAM,1600147,CDM,320,RC,74300,HCPCS,outpatient,,,361.42,216.85,,271.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,271.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.05,325.28,
ORBITS 4+ VIEWS,1600033,CDM,320,RC,70200,HCPCS,outpatient,,,324.82,194.89,,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,292.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.56,292.34,
ORBITS FOR FOREIGN BODY,1600673,CDM,320,RC,70030,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.43,217.1,
PATELLA LEFT,1600567,CDM,320,RC,73562LT,HCPCS,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,143.83,
PATELLA RT,1600035,CDM,320,RC,73562RT,HCPCS,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,143.83,
PELVIMETRY,1600083,CDM,320,RC,74710,HCPCS,outpatient,,,442.01,265.21,,331.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,94.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,331.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,397.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,331.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,331.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,90.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,90.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,397.81,
PELVIS +3 VIEWS,1600037,CDM,320,RC,72190,HCPCS,outpatient,,,290.39,174.23,,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,261.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.5,286.93,
Radiologic examination of the pelvis,1600034,CDM,320,RC,72170,HCPCS,outpatient,,,284.1,170.46,,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,255.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,286.93,
SACROILIAC JOINTS 3+ VIEWS,1600039,CDM,320,RC,72202,HCPCS,outpatient,,,315.8,189.48,,236.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,67.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,236.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,284.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,236.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.71,286.93,
SACRUM,1620053,CDM,320,RC,72220,HCPCS,outpatient,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,260.37,
SACRUM & COCCYX,1600004,CDM,320,RC,72220,HCPCS,outpatient,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,260.37,
SCAPULA BILATERAL,1600313,CDM,320,RC,7301050,HCPCS,outpatient,,,376.99,226.19,,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,339.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,282.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,188.5,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.25,339.29,
SCAPULA LEFT,1600568,CDM,320,RC,73010LT,HCPCS,outpatient,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,173.58,
SCAPULA RT,1600040,CDM,320,RC,73010RT,HCPCS,outpatient,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,96.44,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.52,173.58,
SCOLIOSIS 1 VIEW,1600038,CDM,320,RC,72081,HCPCS,outpatient,,,292.31,175.39,,219.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,62.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,62.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,219.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,263.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,219.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.89,263.08,
SCOLIOSIS 2 OR 3 VIEWS,1600760,CDM,320,RC,72082,HCPCS,outpatient,,,140.08,84.05,,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,286.93,
SELLA TURCICA,1600665,CDM,320,RC,70240,HCPCS,outpatient,,,242.59,145.55,,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,218.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.71,218.33,
SHOULDER BILAT ONE VIEW EACH,1600662,CDM,320,RC,7302050,HCPCS,outpatient,,,226.47,135.88,,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.4,203.82,
SHOULDER BILATERAL,1600314,CDM,320,RC,7303050,HCPCS,outpatient,,,415.51,249.31,,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,373.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,311.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,207.76,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.14,373.96,
SHOULDER LT ROUTINE,1600570,CDM,320,RC,73030LT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
SHOULDER ONE VIEW LT,1600683,CDM,320,RC,73020LT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
SHOULDER ONE VIEW RT,1600667,CDM,320,RC,73020RT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
SHOULDER RT ROUTINE,1600089,CDM,320,RC,73030RT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
SHUNTOGRAM,1620089,CDM,320,RC,77075,HCPCS,outpatient,,,868.18,520.91,,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,694.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,184.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,184.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,781.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,177.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,177.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,781.36,
SINUS LIMITED (LESS THAN 3 VIEWS),1600082,CDM,320,RC,70210,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.43,217.1,
SINUS SERIES,1600041,CDM,320,RC,70220,HCPCS,outpatient,,,165.83,99.5,,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,149.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.98,204.32,
SINUS TRACT OR FISTULA STUDY,1600177,CDM,320,RC,76080,HCPCS,outpatient,,,1134.52,680.71,,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,907.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,575.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,451.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1021.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1232.85,160,,,fee schedule,160% UHC fee schedule for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,1232.85,
SKELETAL SURVEY INFANT,1620082,CDM,320,RC,77076,HCPCS,outpatient,,,470.42,282.25,,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,376.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,100.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,423.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,352.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,423.38,
SKULL LESS THAN 4 VIEWS,1600042,CDM,320,RC,70250,HCPCS,outpatient,,,290.94,174.56,,218.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,218.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,261.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,218.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.61,286.93,
SKULL ROUTINE,1600044,CDM,320,RC,70260,HCPCS,outpatient,,,325.63,195.38,,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,293.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.72,293.07,
SM. BOWEL FOLLOW-THR,1600139,CDM,320,RC,74250,HCPCS,outpatient,,,361.69,217.01,,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,77.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,325.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.11,466.48,
SOFT TISSUE NECK,1600097,CDM,320,RC,70360,HCPCS,outpatient,,,160.09,96.05,,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.8,204.32,
SPINE - SINGLE VIEW - SPECIFY LEVEL,1600679,CDM,320,RC,72020,HCPCS,outpatient,,,160.09,96.05,,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.8,204.32,
STERNO-CLAVICULAR JT 3+V,1600052,CDM,320,RC,71130,HCPCS,outpatient,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,260.37,
STERNUM 2+V,1600053,CDM,320,RC,71120,HCPCS,outpatient,,,216.91,130.15,,162.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,46.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,195.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.44,204.32,
THERAPEUTIC ENEMA,1600036,CDM,320,RC,74283,HCPCS,outpatient,,,452.39,271.43,,339.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.91,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,96.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,339.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,407.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,339.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,339.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.69,466.48,
"Radiologic examination of the middle spine, 2 views",1600680,CDM,320,RC,72070,HCPCS,outpatient,,,140.08,84.05,,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,286.93,
"Radiologic examination of the middle spine, 3 views",1600047,CDM,320,RC,72072,HCPCS,outpatient,,,140.08,84.05,,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.7,286.93,
THOROCOLUMBAR SPINE 2+ VIEWS,1600050,CDM,320,RC,72080,HCPCS,outpatient,,,321.54,192.92,,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,289.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,289.39,
TM JTS BILAT OPEN/CLOSED MOUTH,1600054,CDM,320,RC,70330,HCPCS,outpatient,,,357.32,214.39,,267.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,76.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,267.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,321.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.21,321.59,
TOE BILATERAL,1600315,CDM,320,RC,7366050,HCPCS,outpatient,,,226.2,135.72,,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,203.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,169.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,113.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.35,203.58,
TOE LEFT,1600571,CDM,320,RC,73660LT,HCPCS,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,143.83,
TOE RT,1600055,CDM,320,RC,73660RT,HCPCS,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,79.91,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,143.83,
TRANSCATHETER INTRO OF INTRAVASCULAR STE,1600702,CDM,320,RC,75960,HCPCS,outpatient,,,1233.69,740.21,,925.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,986.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,262.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,262.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,925.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1110.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,925.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,925.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,616.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252.78,1110.32,
"TRANSCATHETER THERAPY,EMBOLIZATION",1600705,CDM,320,RC,75894,HCPCS,outpatient,,,958.04,574.82,,718.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,766.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,204.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,718.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,862.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,718.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.3,862.24,
TRANSLUMINAL BALLOON ANGIOPLASTY,1600695,CDM,320,RC,75962,HCPCS,outpatient,,,3350.86,2010.52,,2513.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2680.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,713.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,713.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2513.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,720.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3015.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2513.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2513.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2513.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2513.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,686.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1675.43,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,686.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,686.59,3015.77,
"TRANSLUMINAL BALLOON ANGIOPLASTY,VENOUS",1600696,CDM,320,RC,75978,HCPCS,outpatient,,,12364.48,7418.69,,9273.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9891.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2633.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2633.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2658.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11128.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,9273.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9273.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9273.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9273.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2533.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6182.24,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2533.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2533.48,11128.03,
UNLISTED X-RAY PROCEDURE,1600319,CDM,320,RC,76499,HCPCS,outpatient,,,151.89,91.13,,113.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,136.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,113.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.12,204.32,
UPPER EXT-INFANT-+2 VIEWS,1600685,CDM,320,RC,73092,HCPCS,outpatient,,,284.1,170.46,,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,255.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.21,286.93,
URETHROGRAM,1600404,CDM,320,RC,74450,HCPCS,outpatient,,,724.48,434.69,,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,579.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,154.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,155.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,652.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,543.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.45,652.03,
Ultrasound of head and neck,1600178,CDM,320,RC,76536,HCPCS,outpatient,,,572.87,343.72,,429.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,122.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,122.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,429.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,515.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,429.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,429.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,117.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,117.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,515.58,
Ultrasound of head and neck,1600138,CDM,320,RC,76536,HCPCS,outpatient,,,344.02,206.41,,258.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,73.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,309.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,70.49,309.62,
VENOGRAM BILAT,1600140,CDM,320,RC,75822,HCPCS,outpatient,,,3207.97,1924.78,,2405.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2566.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1701.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,683.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,683.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2405.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,689.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1334.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2887.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2405.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2405.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2405.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2405.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,657.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4175.7,160,,,fee schedule,160% UHC fee schedule for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,657.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,657.31,4175.7,
VENOGRAM LT,1600678,CDM,320,RC,75820LT,HCPCS,outpatient,,,2209.49,1325.69,,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1767.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,470.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1988.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1104.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,1988.54,
VENOGRAM RT,1600056,CDM,320,RC,75820RT,HCPCS,outpatient,,,2209.49,1325.69,,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1767.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,470.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1988.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1104.75,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,1988.54,
"VENOGRAPHY,CAVAL,INFERIOR WITH SERIALOGR",1600707,CDM,320,RC,75825,HCPCS,outpatient,,,5951.27,3570.76,,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4761.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3406.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1267.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1267.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2672.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5356.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1219.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7094.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1219.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1219.42,7094.48,
"VENOGRAPHY,CAVAL,SUPERIOR WITH SERIALOGR",1600701,CDM,320,RC,75827,HCPCS,outpatient,,,1725.41,1035.25,,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1380.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1701.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,367.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,367.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1334.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1552.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1614.11,160,,,fee schedule,160% UHC fee schedule for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,1701.28,
"VENOGRAPHY,VENOUS SINUS OR JUGULAR CATHE",1600708,CDM,320,RC,75860,HCPCS,outpatient,,,5951.27,3570.76,,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4761.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3406.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1267.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1267.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2672.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5356.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1219.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7094.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1219.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1219.42,7094.48,
VOIDING CYSTO-URETHROGRAM,1600072,CDM,320,RC,74455,HCPCS,outpatient,,,725.85,435.51,,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,580.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,154.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,653.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,544.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.73,653.27,
WRIST 2VIEW BILAT,1600067,CDM,320,RC,7310050,HCPCS,outpatient,,,204.62,122.77,,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.31,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.93,184.16,
WRIST BILAT 3+V,1600316,CDM,320,RC,7311050,HCPCS,outpatient,,,303.23,181.94,,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,272.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.13,272.91,
WRIST LT 2 VIEWS,1600686,CDM,320,RC,73100LT,HCPCS,outpatient,,,186.32,111.79,,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,167.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.16,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.18,167.69,
WRIST LT ROUTINE 3+ VIEWS,1600572,CDM,320,RC,73110LT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
WRIST RT 2 VIEWS,1600669,CDM,320,RC,73100RT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
WRIST RT ROUTINE 3+ VIEWS,1600057,CDM,320,RC,73110RT,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.32,93.63,
ZYGOMATIC ARCHES,1600058,CDM,320,RC,70150,HCPCS,outpatient,,,321.54,192.92,,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,289.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.88,289.39,
"ANGIOGRAPHY, EXTREMITY, BILATERAL",1600700,CDM,323,RC,75716,HCPCS,outpatient,,,5387.15,3232.29,,4040.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4309.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3406.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1147.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1147.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1158.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2672.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,4848.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4040.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4040.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4040.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4040.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1103.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7094.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1103.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2620.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1103.83,7094.48,
"ANGIOGRAPHY, EXTREMITY, UNI LT",1600697,CDM,323,RC,75710LT,HCPCS,outpatient,,,5951.27,3570.76,,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4761.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1267.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1267.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5356.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1219.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2975.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1219.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1219.42,5356.14,
"ANGIOGRAPHY, EXTREMITY, UNI RT",1600752,CDM,323,RC,75710RT,HCPCS,outpatient,,,5951.27,3570.76,,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4761.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1267.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1267.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1279.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5356.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4463.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1219.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2975.64,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1219.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1219.42,5356.14,
"ANGIOGRAPHY, FOLLOW UP",1600706,CDM,323,RC,75898,HCPCS,outpatient,,,1725.41,1035.25,,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1380.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3406.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,367.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,367.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,370.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2672.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1552.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4175.7,160,,,fee schedule,160% UHC fee schedule for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,4175.7,
"2 views, front and back",1600159,CDM,324,RC,71046,HCPCS,outpatient,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,173.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.52,204.32,
"2 views, front and back",1600128,CDM,324,RC,71046,HCPCS,outpatient,,,401.84,241.1,,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,85.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,361.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,301.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,361.66,
3 views,1600012,CDM,324,RC,71047,HCPCS,outpatient,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,260.37,
3 views,1600013,CDM,324,RC,71047,HCPCS,outpatient,,,289.3,173.58,,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,260.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.28,260.37,
Single view,1600010,CDM,324,RC,71045,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.32,204.32,
Single view,1600075,CDM,324,RC,71045,HCPCS,outpatient,,,104.03,62.42,,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,93.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.32,204.32,
"2 views, front and back",1600011,CDM,324,RC,71046,HCPCS,outpatient,,,532.51,319.51,,399.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,113.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,399.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,77.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,479.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,399.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,109.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.32,160,,,fee schedule,160% UHC fee schedule for outpatient setting,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,109.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,76.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.41,479.26,
RIBS BILAT ROUTINE 4+ VIEWS,1600015,CDM,324,RC,71111,HCPCS,outpatient,,,422.61,253.57,,316.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,90.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,316.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,380.35,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,316.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.59,380.35,
RIBS UNILAT ROUTINE 3+ VIEWS LT,1600014,CDM,324,RC,71101LT,HCPCS,outpatient,,,353.76,212.26,,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,318.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,176.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,318.38,
RIBS UNILAT ROUTINE 3+ VIEWS RT,1600028,CDM,324,RC,71101RT,HCPCS,outpatient,,,353.76,212.26,,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,318.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,176.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.49,318.38,
RIBS-BILAT(3 VIEWS),1600676,CDM,324,RC,71110,HCPCS,outpatient,,,401.03,240.62,,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,320.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,85.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,360.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,300.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.17,360.93,
RIBS-UNILAT 2 VIEWS LT,1600043,CDM,324,RC,71100LT,HCPCS,outpatient,,,267.72,160.63,,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,133.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,240.95,
RIBS-UNILAT 2 VIEWS RT,1600675,CDM,324,RC,71100RT,HCPCS,outpatient,,,267.72,160.63,,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,133.86,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.86,240.95,
CHEMOTHERAPY ADMINISTRATION SQ OR IM,2500036,CDM,331,RC,96401,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,905,100,,,case rate,100% UHC case rate for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,905,
Chemotherapy infusion-each additional hour,2500051,CDM,335,RC,96415,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.52,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,905,100,,,case rate,100% UHC case rate for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,905,
CHEMOTHERAPY ADMIN INFUSION UP TO 1 HR,2500037,CDM,335,RC,96413,HCPCS,outpatient,,,704.53,422.72,,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,563.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,380.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,150.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,298.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,634.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,144.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,905,100,,,case rate,100% UHC case rate for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,144.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,144.36,905,
***DNU*****NM HIDA SCAN,1600106,CDM,341,RC,78223,HCPCS,outpatient,,,1423.54,854.12,,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1281.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,896.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.68,1281.19,
DNU******NM HIDA W CCK,1600095,CDM,341,RC,78223,HCPCS,outpatient,,,1423.54,854.12,,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1281.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,896.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,291.68,1281.19,
NM BONE SCAN LIMITED,1600101,CDM,341,RC,78300,HCPCS,outpatient,,,949.04,569.42,,711.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,202.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,711.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,854.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,711.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,711.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,194.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,597.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,194.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,194.46,854.14,
NM BONE SCAN MULTIPLE,1600100,CDM,341,RC,78305,HCPCS,outpatient,,,1898.06,1138.84,,1423.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,404.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,404.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1423.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1708.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1423.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1423.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1423.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1423.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,388.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1195.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,388.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,1708.25,
NM BONE SCAN TRIPLE PHASE,1600098,CDM,341,RC,78315,HCPCS,outpatient,,,1467.53,880.52,,1100.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1174.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,312.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,312.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1100.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,315.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1320.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1100.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1100.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,300.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,924.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,300.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,300.7,1320.78,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",1600102,CDM,341,RC,78306,HCPCS,outpatient,,,1423.54,854.12,,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1281.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,896.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,1281.19,
Image of the heart to assess perfusion,1600112,CDM,341,RC,78452,HCPCS,outpatient,,,7344.93,4406.96,,5508.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5875.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1517.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1564.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1564.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1579.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1190.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,6610.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5508.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5508.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5508.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5508.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1504.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4627.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1504.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1167.44,6610.44,
NM CARDIAC STRESS OR REST ONLY,1600111,CDM,341,RC,78451,HCPCS,outpatient,,,3858.14,2314.88,,2893.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3086.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1517.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,821.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,821.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2893.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,829.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1190.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3472.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2893.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2893.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2893.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2893.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,790.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2430.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,790.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,790.53,3472.33,
NM GALLIUM SCAN TUMOR LOCALIZATION,1600104,CDM,341,RC,78802,HCPCS,outpatient,,,2871.69,1723.01,,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2297.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1517.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,611.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,611.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,617.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1190.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2584.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1809.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,2584.52,
NM GASTRIC EMPTYING STUDY,1600135,CDM,341,RC,78264,HCPCS,outpatient,,,1059.67,635.8,,794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,225.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,953.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,217.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,667.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,217.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,217.13,953.7,
NM HIDA SCAN,1600189,CDM,341,RC,78226,HCPCS,outpatient,,,1423.54,854.12,,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1281.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,896.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,1281.19,
NM HIDA SCAN W EF,1600188,CDM,341,RC,78227,HCPCS,outpatient,,,1683.07,1009.84,,1262.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,576.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,358.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,358.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1262.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,452.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1514.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1262.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1262.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1262.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1262.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,344.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1060.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,344.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,344.86,1514.76,
NM LIVER SCAN,1600107,CDM,341,RC,78803,HCPCS,outpatient,,,2871.69,1723.01,,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2297.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1517.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,611.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,611.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,617.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1190.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2584.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1809.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,2584.52,
NM LIVER-SPLEEN,1600105,CDM,341,RC,78215,HCPCS,outpatient,,,1423.54,854.12,,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1281.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,896.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,1281.19,
NM LUNG SCAN VENT/PERFUSION,1600109,CDM,341,RC,78582,HCPCS,outpatient,,,1423.54,854.12,,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,576.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,452.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1281.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,896.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,1281.19,
NM MECKEL'S SCAN,1600110,CDM,341,RC,78290,HCPCS,outpatient,,,1423.54,854.12,,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1281.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,896.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,1281.19,
NM MYO PERF W WALL MOTION,1600113,CDM,341,RC,78451,HCPCS,outpatient,,,2871.69,1723.01,,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2297.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1517.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,611.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,611.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,617.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1190.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2584.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2153.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1809.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1167.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,588.41,2584.52,
NM MYOCARDIAL INFARCTION SCAN,1600191,CDM,341,RC,78466,HCPCS,outpatient,,,4066.85,2440.11,,3050.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3253.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,866.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,866.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3050.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,874.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3660.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3050.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3050.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3050.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3050.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,833.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2562.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,833.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,3660.17,
NM PARATHYROID SCAN,1600190,CDM,341,RC,78070,HCPCS,outpatient,,,1423.54,854.12,,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1138.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,303.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1281.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1067.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,896.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.68,1281.19,
NM PERFUSION LUNG SCAN,1600187,CDM,341,RC,78580,HCPCS,outpatient,,,1245.17,747.1,,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,265.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,265.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1120.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,255.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,784.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,255.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,255.14,1120.65,
NM RENAL SCAN,1600114,CDM,341,RC,78707,HCPCS,outpatient,,,1372.19,823.31,,1029.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1097.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,576.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,292.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,292.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1029.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,295.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,452.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1234.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1029.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1029.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,281.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,864.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,281.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,443.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,281.16,1234.97,
NM TESTICULAR SCAN,1600200,CDM,341,RC,78761,HCPCS,outpatient,,,839.49,503.69,,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,178.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,755.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,528.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,755.54,
NM THYROID SCAN,1600119,CDM,341,RC,78013,HCPCS,outpatient,,,839.49,503.69,,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,178.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,755.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,528.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,755.54,
Scan using a radioactive medication (radiopharmaceutical) to take pictures or images of the thyroid gland.,1610065,CDM,341,RC,78014,HCPCS,outpatient,,,1175.5,705.3,,881.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,940.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,250.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,250.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,881.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1057.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,881.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,881.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,881.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,881.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,240.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,740.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,240.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,240.86,1057.95,
NM THYROID UPTAKE,1600092,CDM,341,RC,78012,HCPCS,outpatient,,,839.49,503.69,,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,671.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,178.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,755.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,629.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,528.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,172.01,755.54,
NM VENTILATON LUNG SCAN,1600161,CDM,341,RC,78579,HCPCS,outpatient,,,1245.17,747.1,,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,996.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,444.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,265.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,265.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,348.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1120.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,933.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,255.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,784.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,255.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,255.14,1120.65,
NM I-123 CAPSULE PER 100 MICROCURIES,1600134,CDM,343,RC,A9516,HCPCS,outpatient,,,390.92,234.55,,293.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.74,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,84.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,351.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,293.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.1,351.83,
NM TC99M CARDIOLITE UP TO 40 MCI/DOSE,1600118,CDM,343,RC,A9500,HCPCS,outpatient,,,509.49,305.69,,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,407.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,458.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,382.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,320.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,104.39,458.54,
NM Tc99m CHOLETEC PER DOSE,1600117,CDM,343,RC,A9537,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.5,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,151.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,217.1,
NM Tc99m DTPA AEROSOL up to 75 mCi/dose,1600099,CDM,343,RC,A9567,HCPCS,outpatient,,,235.21,141.13,,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,148.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.19,211.69,
NM Tc99m DTPA up to 25 mCi/DOSE,1600120,CDM,343,RC,A9539,HCPCS,outpatient,,,235.21,141.13,,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,50.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,211.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,148.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,211.69,
NM TC99M LABELED RBC UP TO 30 MCI,1600192,CDM,343,RC,A9560,HCPCS,outpatient,,,134.4,80.64,,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,28.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.54,120.96,
NM Tc99m MAA up to 10 mCi/DOSE,1600103,CDM,343,RC,A9540,HCPCS,outpatient,,,128.67,77.2,,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,27.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,115.8,
NM Tc99m MAG-3,1600096,CDM,343,RC,A9562,HCPCS,outpatient,,,971.99,583.19,,728.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,777.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,207.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,207.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,728.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,874.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,728.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,612.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.16,874.79,
NM TC99M MYOVIEW UP TO 40MCI/DOSE,1600136,CDM,343,RC,A9502,HCPCS,outpatient,,,582.98,349.79,,437.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.46,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,125.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,524.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,437.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,367.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.46,524.68,
NM TC99M PER 20 MCI,1600130,CDM,343,RC,A9512,HCPCS,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.6,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,11.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.6,49.42,
NM Tc99m SULFUR COLLOID up to 20mCi/DOSE,1600129,CDM,343,RC,A9541,HCPCS,outpatient,,,705.09,423.05,,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,564.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,267.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,151.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,634.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,528.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,444.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.47,634.58,
NM THALLIUM-201 CHLORIDE PER MCI,1600141,CDM,343,RC,A9505,HCPCS,outpatient,,,221.82,133.09,,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.48,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,47.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,199.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,139.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.45,199.64,
CT-MRI-OTHER POST PROCESSING,1610057,CDM,350,RC,76377,HCPCS,outpatient,,,496.65,297.99,,372.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,372.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,446.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,372.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.76,446.99,
CTA LOWER EXT,1610024,CDM,350,RC,73706,HCPCS,outpatient,,,1794.81,1076.89,,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1615.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,1615.33,
CT HEAD W/ & W/O CONT,1610002,CDM,351,RC,70470,HCPCS,outpatient,,,4086.03,2451.62,,3064.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3268.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,870.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,870.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3064.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,878.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3677.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3064.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3064.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3064.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3064.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,837.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,837.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3677.43,
CT scan head or brain without dye,1610000,CDM,351,RC,70450,HCPCS,outpatient,,,1012.49,607.49,,759.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,809.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,215.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,215.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,759.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,911.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,759.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,759.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,207.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,207.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,911.24,
CT HEAD WITH CONTRAST,1610001,CDM,351,RC,70460,HCPCS,outpatient,,,2537.31,1522.39,,1902.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2029.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1902.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2283.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1902.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,519.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,519.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2283.58,
CT Scan of the face and jaw without dye,1610035,CDM,351,RC,70486,HCPCS,outpatient,,,2874.73,1724.84,,2156.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2299.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,612.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,612.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2156.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,618.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2587.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2156.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2156.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2156.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2156.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,589.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,589.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,2587.26,
CT MAXILLOFACIAL W/WO CONTRAST,1610039,CDM,351,RC,70488,HCPCS,outpatient,,,4099.15,2459.49,,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3279.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,881.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3689.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3689.24,
CT MAXILLOFACIAL WITH CONTRAST,1610061,CDM,351,RC,70487,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2284.66,
"CT ORBIT, SELLA , EAR W/O CONTRAST",1610032,CDM,351,RC,70480,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1781.72,
"CT ORBIT, SELLA, EAR W/WO CONTRAST",1610033,CDM,351,RC,70482,HCPCS,outpatient,,,4099.15,2459.49,,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3279.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,881.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3689.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3689.24,
"CT ORBIT, SELLA, EAR WITH CONTRAST",1610055,CDM,351,RC,70481,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2284.66,
CT SCANOGRAM,1610026,CDM,351,RC,77073,HCPCS,outpatient,,,1738.96,1043.38,,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1391.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,370.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1565.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,356.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,356.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,1565.06,
CT SOFT TISSUE NECK W/O CONT,1610028,CDM,351,RC,70490,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1781.72,
CT SOFT TISSUE NECK W/WO CONT,1610029,CDM,351,RC,70492,HCPCS,outpatient,,,2963.58,1778.15,,2222.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2370.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,631.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,631.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2222.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,637.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2667.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2222.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2222.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2222.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2222.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,607.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,607.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2667.22,
CT scan of neck with dye,1610027,CDM,351,RC,70491,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2284.66,
CTA CAROTID,1610020,CDM,351,RC,70498,HCPCS,outpatient,,,2080.99,1248.59,,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1664.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,443.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,443.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1872.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,1872.89,
CTA HEAD,1610019,CDM,351,RC,70496,HCPCS,outpatient,,,2080.99,1248.59,,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1664.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,443.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,443.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1872.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1560.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,1872.89,
"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",1610064,CDM,352,RC,74178,HCPCS,outpatient,,,5729.07,3437.44,,4296.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4583.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1220.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1220.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1231.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5156.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4296.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4296.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4296.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4296.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1173.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1173.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,5156.16,
CT of abdomen with and without dye,1610008,CDM,352,RC,74170,HCPCS,outpatient,,,3760.08,2256.05,,2820.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3008.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,800.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,800.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2820.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,808.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3384.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2820.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2820.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2820.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2820.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,770.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,770.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3384.07,
CT of abdomen with dye,1610007,CDM,352,RC,74160,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2284.66,
CT of abdomen without dye,1610006,CDM,352,RC,74150,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1781.72,
CT scan of abdomen and pelvis with contrast,1610063,CDM,352,RC,74177,HCPCS,outpatient,,,5097.47,3058.48,,3823.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4077.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1085.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1085.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1095.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,4587.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3823.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3823.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3823.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3823.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1044.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1044.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,4587.72,
CT of abdomen and pelvis without dye,1610062,CDM,352,RC,74176,HCPCS,outpatient,,,4093.22,2455.93,,3069.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3274.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,871.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,871.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3069.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,880.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3683.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3069.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3069.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3069.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3069.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,838.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,838.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,3683.9,
CT CERVICAL SPINE WITH CONTRAST,1610050,CDM,352,RC,72126,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2284.66,
CT CERVICAL SPINE WITH/WITHOUT CONTRAST,1610018,CDM,352,RC,72127,HCPCS,outpatient,,,3672.88,2203.73,,2754.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2938.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,782.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,782.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2754.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,789.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3305.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2754.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2754.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2754.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2754.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,752.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,752.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3305.59,
CT CERVICAL SPINE WO/CONT,1610015,CDM,352,RC,72125,HCPCS,outpatient,,,1153.6,692.16,,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,922.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,245.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1038.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1038.24,
CT CHEST W/ & W/O CONT,1610005,CDM,352,RC,71270,HCPCS,outpatient,,,3991.73,2395.04,,2993.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3193.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,850.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2993.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,858.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3592.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2993.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2993.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2993.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2993.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,817.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,817.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3592.56,
CT scan of the thorax with dye,1610004,CDM,352,RC,71260,HCPCS,outpatient,,,3683.28,2209.97,,2762.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2946.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,784.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,784.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2762.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,791.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3314.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2762.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2762.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2762.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2762.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,754.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,754.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3314.95,
CT scan of the thorax without dye,1610003,CDM,352,RC,71250,HCPCS,outpatient,,,1153.6,692.16,,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,922.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,245.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1038.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1038.24,
CT LOWER EXT W CONTRAST BILAT,1610059,CDM,352,RC,7370150,HCPCS,outpatient,,,3389.97,2033.98,,2542.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2711.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,722.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,722.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2542.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,728.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3050.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2542.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2542.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2542.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2542.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1694.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,694.6,3050.97,
CT LOWER EXT W CONTRAST LT,1610013,CDM,352,RC,73701LT,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1269.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,2284.66,
CT LOWER EXT W CONTRAST RT,1610060,CDM,352,RC,73701RT,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1269.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,2284.66,
CT LOWER EXT W/O CONT LT,1610012,CDM,352,RC,73700LT,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,989.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,1781.72,
CT LOWER EXT W/O CONTRAST BILAT,1610034,CDM,352,RC,7370050,HCPCS,outpatient,,,2483.66,1490.2,,1862.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1986.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,529.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,529.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1862.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,533.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2235.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1862.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1862.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1862.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1862.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1241.83,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.9,2235.29,
CT LOWER EXT W/O CONTRAST RT,1610036,CDM,352,RC,73700RT,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,989.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,1781.72,
CT LOWER EXT W/WO CONTRAST BILAT,1610037,CDM,352,RC,7370250,HCPCS,outpatient,,,3957.1,2374.26,,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3165.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,842.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,842.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3561.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,810.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1978.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,810.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,810.81,3561.39,
CT LOWER EXT W/WO CONTRAST LT,1610014,CDM,352,RC,73702LT,HCPCS,outpatient,,,3105.75,1863.45,,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2484.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,661.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,661.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2795.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1552.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636.37,2795.18,
CT LOWER EXT W/WO CONTRAST RT,1610049,CDM,352,RC,73702RT,HCPCS,outpatient,,,3105.75,1863.45,,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2484.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,661.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,661.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,667.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2795.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2329.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1552.88,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,636.37,2795.18,
CT LUMBAR SPINE WITH AND W/O CONTRAST,1610054,CDM,352,RC,72133,HCPCS,outpatient,,,4099.15,2459.49,,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3279.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,881.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3689.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3689.24,
CT LUMBAR SPINE WITH CONTRAST,1610053,CDM,352,RC,72132,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2284.66,
CT scan of lower spine without dye,1610017,CDM,352,RC,72131,HCPCS,outpatient,,,1153.6,692.16,,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,922.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,245.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1038.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1038.24,
CT PELVIS W/ and W/O CONTRAST,1610011,CDM,352,RC,72194,HCPCS,outpatient,,,4099.15,2459.49,,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3279.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,881.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3689.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,3689.24,
CT of pelvis without dye,1610009,CDM,352,RC,72192,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1781.72,
"CT scan, pelvis, with contrast",1610010,CDM,352,RC,72193,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2284.66,
CT THORACIC SPINE W/WO CONTRAST,1610052,CDM,352,RC,72130,HCPCS,outpatient,,,2914.74,1748.84,,2186.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2331.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,620.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,620.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2186.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,626.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2623.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2186.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2186.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2186.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2186.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,597.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,597.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2623.27,
CT THORACIC SPINE WITH CONTRAST,1610051,CDM,352,RC,72129,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,2284.66,
CT THORACIC SPINE WO/CONT,1610016,CDM,352,RC,72128,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1781.72,
CT UPPER EXT W/O CONTRAST RT,1610042,CDM,352,RC,73200RT,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,989.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,1781.72,
CT UPPER EXTREMITY W/O CONTRAST BILAT,1610044,CDM,352,RC,7320050,HCPCS,outpatient,,,3335.01,2001.01,,2501.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2668.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,710.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,710.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2501.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,717.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3001.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2501.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2501.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2501.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2501.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,683.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1667.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,683.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,683.34,3001.51,
CT UPPER EXTREMITY W/O CONTRAST LEFT,1610047,CDM,352,RC,73200LT,HCPCS,outpatient,,,1979.69,1187.81,,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1583.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,421.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1781.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1484.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,989.85,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,405.64,1781.72,
CT UPPER EXTREMITY W/WO CONTRAST BILAT,1610048,CDM,352,RC,7320250,HCPCS,outpatient,,,4099.15,2459.49,,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3279.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,873.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,881.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3689.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3074.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2049.58,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,839.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,839.92,3689.24,
CT UPPER EXTREMITY W/WO CONTRAST LT,1610056,CDM,352,RC,73202LT,HCPCS,outpatient,,,2474.04,1484.42,,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1979.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,526.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2226.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1237.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.93,2226.64,
CT UPPER EXTREMITY W/WO CONTRAST RT,1610040,CDM,352,RC,73202RT,HCPCS,outpatient,,,2474.04,1484.42,,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1979.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,526.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,526.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2226.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1855.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1237.02,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,506.93,2226.64,
CT UPPER EXTREMITY WITH CONTRAST BILAT,1610045,CDM,352,RC,7320150,HCPCS,outpatient,,,3957.1,2374.26,,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3165.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,842.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,842.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3561.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2967.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,810.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1978.55,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,810.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,810.81,3561.39,
CT UPPER EXTREMITY WITH CONTRAST LEFT,1610046,CDM,352,RC,73201LT,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1269.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,2284.66,
CT UPPER EXTREMITY WITH CONTRAST RT,1610041,CDM,352,RC,73201RT,HCPCS,outpatient,,,2538.51,1523.11,,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2030.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2284.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1903.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1269.26,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,520.14,2284.66,
"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",1600184,CDM,352,RC,74178,HCPCS,outpatient,,,4892.9,2935.74,,3669.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3914.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1042.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1042.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3669.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1051.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,4403.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3669.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3669.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3669.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3669.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1002.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1002.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,4403.61,
CTA ABDOMEN,1610025,CDM,352,RC,74175,HCPCS,outpatient,,,1794.81,1076.89,,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1615.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,1615.33,
CTA ABDOMEN AND PELVIS W/WO CONTRAST,1600186,CDM,352,RC,74174,HCPCS,outpatient,,,2026.78,1216.07,,1520.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1621.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,431.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,431.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1520.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,435.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1824.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1520.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,415.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,415.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,1824.1,
CTA AORTA RUNOFF,1610030,CDM,352,RC,75635,HCPCS,outpatient,,,1794.81,1076.89,,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1615.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,1615.33,
CTA PELVIS,1610022,CDM,352,RC,72191,HCPCS,outpatient,,,1794.81,1076.89,,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1615.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,1615.33,
Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,1610021,CDM,352,RC,71275,HCPCS,outpatient,,,1212.31,727.39,,909.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,969.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,258.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,909.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1091.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,909.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,248.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,248.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,1091.08,
CTA UPPER EXTREMITY,1610023,CDM,352,RC,73206,HCPCS,outpatient,,,1794.81,1076.89,,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1435.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,382.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,161.79,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1615.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1346.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,466.48,160,,,fee schedule,160% UHC fee schedule for outpatient setting,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,367.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.62,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.62,1615.33,
CT GUIDED PERCUTANEOUS DRAINAGE W CATHET,1600146,CDM,359,RC,75989,HCPCS,outpatient,,,2015.85,1209.51,,1511.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.68,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,429.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,429.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1511.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1814.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1511.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1511.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1511.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1511.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,413.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,413.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,413.05,1814.27,
CT NEEDLE BIOPSY,1610038,CDM,359,RC,77012,HCPCS,outpatient,,,1738.96,1043.38,,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1391.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,370.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,373.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1565.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1304.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.31,1565.06,
ANGIOGRAPHY ARTERIOVENOUS SHUNT,1600753,CDM,360,RC,,,outpatient,,,2768.43,1661.06,,2076.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2214.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,589.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,589.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2076.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,595.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2491.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2076.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2076.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2076.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2076.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1744.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,567.25,2491.59,
"ANGIOGRAPHY, ARTERIOVENOUS SHUNT",1600694,CDM,360,RC,,,outpatient,,,2209.49,1325.69,,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1767.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,470.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,470.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,475.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1988.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1657.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1391.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,452.72,1988.54,
BRACHIAL PLEXUS BLOCK CONT INFUSION,2400014,CDM,360,RC,64416,HCPCS,outpatient,,,2150.21,1290.13,,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,462.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1935.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,1935.19,
BRACHIAL PLEXUS BLOCK INJECTION,2400003,CDM,360,RC,64415,HCPCS,outpatient,,,1058.84,635.3,,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,225.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,227.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,952.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,216.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,216.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,216.96,1459.9,
DOUBLE SET-UP,1700003,CDM,360,RC,,,outpatient,,,423.7,254.22,,317.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,317.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,381.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,317.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,317.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.82,381.33,
EPIDURAL CONT INFUSION CERV/THORACIC,2400005,CDM,360,RC,62324,HCPCS,outpatient,,,2150.21,1290.13,,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,462.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1935.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,1935.19,
EPIDURAL CONT INFUSION LUMB/SACRAL,2400004,CDM,360,RC,62326,HCPCS,outpatient,,,2150.21,1290.13,,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,462.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1935.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,1935.19,
EPIDURAL INJECTION CERVICAL/THORACIC,2400007,CDM,360,RC,62320,HCPCS,outpatient,,,2150.21,1290.13,,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,462.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1935.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,1935.19,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,2400006,CDM,360,RC,62322,HCPCS,outpatient,,,2150.21,1290.13,,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,462.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1935.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,1935.19,
EXCISION LESION WITH REPAIR COMPLEX,2500026,CDM,360,RC,,,outpatient,,,435.39,261.23,,326.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,348.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,326.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,326.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,274.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.21,391.85,
EXCISION LESION WITH REPAIR intermediate,2500028,CDM,360,RC,,,outpatient,,,297.16,178.3,,222.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,222.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,267.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,222.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,187.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.89,267.44,
EXCISION LESION WITH REPAIR SIMPLE,2500027,CDM,360,RC,,,outpatient,,,217.48,130.49,,163.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.32,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,163.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,195.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,163.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,137.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.56,195.73,
EXTRACAP CATARACT REM INSRT LT,2400023,CDM,360,RC,66984LT,HCPCS,outpatient,,,4600.66,2760.4,,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3680.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,979.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,979.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,989.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4140.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1200,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.68,4140.59,
EXTRACAP CATARACT REM INSRT RT,2400022,CDM,360,RC,66984RT,HCPCS,outpatient,,,4600.66,2760.4,,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3680.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,979.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,979.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,989.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4140.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3450.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1200,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,942.68,4140.59,
FEMORAL NERVE BLOCK CONT INFUSION,2400013,CDM,360,RC,64448,HCPCS,outpatient,,,1610.95,966.57,,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,343.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,343.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,346.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1449.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,330.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,330.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,330.08,1459.9,
FEMORAL NERVE BLOCK INJECTION,2400015,CDM,360,RC,64447,HCPCS,outpatient,,,816.79,490.07,,612.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,653.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,173.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,173.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,175.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,735.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,612.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,612.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,167.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,167.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,167.36,1459.9,
INTERCOSTAL NERVE BLOCK,2400021,CDM,360,RC,64420,HCPCS,outpatient,,,1278.77,767.26,,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1023.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,272.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,272.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,274.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1150.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,1459.9,
MINOR OR RECOVERY /15 MIN,1000011,CDM,360,RC,,,outpatient,,,169.37,101.62,,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,106.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.7,152.43,
NERVE BLOCK AXILLARY,2400019,CDM,360,RC,64417,HCPCS,outpatient,,,2150.21,1290.13,,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,462.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1935.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,1935.19,
NERVE BLOCK CERV/THORACIC EA ADDTL LEVEL,2400010,CDM,360,RC,64480,HCPCS,outpatient,,,1128.79,677.27,,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,903.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1015.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,389,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,1015.91,
NERVE BLOCK CERV/THORACIC SINGLE LEVEL,2400011,CDM,360,RC,64479,HCPCS,outpatient,,,2150.21,1290.13,,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,462.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1935.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,1935.19,
NERVE BLOCK LUMB/SACRAL EA ADDTL LEVEL,2400008,CDM,360,RC,64484,HCPCS,outpatient,,,1128.79,677.27,,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,903.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1015.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,389,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,1015.91,
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,2400009,CDM,360,RC,64483,HCPCS,outpatient,,,2150.21,1290.13,,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1720.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,457.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,462.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1935.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1612.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,440.58,1935.19,
NERVE BLOCK OTHR PERF NERVE,2400012,CDM,360,RC,64450,HCPCS,outpatient,,,1278.77,767.26,,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1023.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,272.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,272.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,274.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1150.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,1459.9,
OPERATING ROOM,1700001,CDM,360,RC,,,outpatient,,,3085.88,1851.53,,2314.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2468.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,657.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,657.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2314.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,663.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2777.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2314.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2314.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2314.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2314.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,632.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1944.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,632.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,632.3,2777.29,
OR ADDIT 15MIN,1700002,CDM,360,RC,,,outpatient,,,197.76,118.66,,148.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,177.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,124.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.52,177.98,
SCIATIC NERVE BLOCK CONT INFUSION,2400017,CDM,360,RC,64446,HCPCS,outpatient,,,1610.95,966.57,,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1288.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,343.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,343.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,346.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1449.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1208.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,330.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,330.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,330.08,1459.9,
SCIATIC NERVE BLOCK INJECTION,2400016,CDM,360,RC,64445,HCPCS,outpatient,,,1278.77,767.26,,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1023.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,272.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,272.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,274.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1150.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,1459.9,
TAP BLOCK,2400020,CDM,360,RC,64486,HCPCS,outpatient,,,1128.79,677.27,,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,903.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1015.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,389,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.29,1015.91,
VAD BLOOD DRAW,1000036,CDM,360,RC,36592,HCPCS,outpatient,,,251.88,151.13,,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,389,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,389,
Biopsy of prostate gland,1620087,CDM,361,RC,55700,HCPCS,outpatient,,,4146.9,2488.14,,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3317.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2120.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,883.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,883.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,891.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1664.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3732.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,849.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1036,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,849.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,849.7,3732.21,
Procedure on the bladder,1700006,CDM,361,RC,52000,HCPCS,outpatient,,,2392.26,1435.36,,1794.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1913.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,715.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,509.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,509.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,514.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,561.03,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2153.03,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1794.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1794.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,490.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,796,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,490.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,490.17,2153.03,
CYSTOURETHROSCOPY WITH BIOPSY,1700005,CDM,361,RC,52204,HCPCS,outpatient,,,6347.38,3808.43,,4760.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5077.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2120.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1351.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1351.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1364.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1664.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5712.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4760.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4760.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4760.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4760.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1300.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1200,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1300.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1200,5712.64,
SUTURING SIMPLE,2500006,CDM,361,RC,,,outpatient,,,214.2,128.52,,160.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,160.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,134.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.89,192.78,
"WOUND PREP CH/INF, ADDL 100 CM",2810039,CDM,361,RC,15003,HCPCS,outpatient,,,1069.24,641.54,,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,962.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,389,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.09,962.32,
"WOUND PREP CH/INF, TRK/ARM/LEG",2810037,CDM,361,RC,15002,HCPCS,outpatient,,,3599.99,2159.99,,2699.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2879.99,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1973.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,766.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,766.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,774,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1548.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3239.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2699.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2699.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2699.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2699.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,737.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1036,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,737.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,737.64,3239.99,
"WOUND PREP CH/INF,F/N/HF/LG",2810038,CDM,361,RC,15004,HCPCS,outpatient,,,1142.71,685.63,,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,914.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,243.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,243.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,245.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1028.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,234.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,389,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,234.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,234.14,1459.9,
ANES SER ADDIT 15MIN,2400002,CDM,370,RC,,,outpatient,,,80.34,48.2,,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,72.31,
ANESTHESIA SERVICES FIRST HOUR,2400001,CDM,370,RC,,,outpatient,,,2508.05,1504.83,,1881.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2006.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,534.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1881.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,539.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2257.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1881.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1881.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1881.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1881.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,513.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1580.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,513.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,513.9,2257.25,
NERVE BLOCK OTHR PERF NERVE,2400024,CDM,370,RC,64450,HCPCS,outpatient,,,1278.77,767.26,,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1023.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,272.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,272.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,274.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1150.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,959.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,805.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,262.02,1459.9,
AG SCREEN GRP I,1500543,CDM,390,RC,86902,HCPCS,outpatient,,,208.99,125.39,,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,188.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163,100,,,case rate,100% UHC case rate for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,370.6,
AG SCREEN GRP II,1500544,CDM,390,RC,86902,HCPCS,outpatient,,,1600.3,960.18,,1200.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1280.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1200.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1440.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1200.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1200.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163,100,,,case rate,100% UHC case rate for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,1440.27,
AG SCREEN GRP III,1500545,CDM,390,RC,86902,HCPCS,outpatient,,,112.83,67.7,,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,101.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163,100,,,case rate,100% UHC case rate for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,370.6,
AG SCREEN GRP IV,1500546,CDM,390,RC,86902,HCPCS,outpatient,,,127.03,76.22,,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,114.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163,100,,,case rate,100% UHC case rate for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,370.6,
AG SCREEN GRP V,1500547,CDM,390,RC,86902,HCPCS,outpatient,,,141.23,84.74,,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,127.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163,100,,,case rate,100% UHC case rate for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,370.6,
AG SCREEN GRP VI,1500548,CDM,390,RC,86902,HCPCS,outpatient,,,155.17,93.1,,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163,100,,,case rate,100% UHC case rate for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,370.6,
AG SCREEN GRP VII,1500549,CDM,390,RC,86902,HCPCS,outpatient,,,197.51,118.51,,148.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,148.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,177.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,148.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163,100,,,case rate,100% UHC case rate for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.18,370.6,
BB CROSSMATCH,1500029,CDM,390,RC,86922,HCPCS,outpatient,,,306.94,184.16,,230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,276.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.89,276.25,
BB CRYOPRECIPATE,1500234,CDM,390,RC,P9012,HCPCS,outpatient,,,155.98,93.59,,116.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,75.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,140.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.96,163,
BB FRESH FROZEN PLASMA,1500415,CDM,390,RC,P9017,HCPCS,outpatient,,,106.09,63.65,,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,111.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,87.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,95.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.74,163,
BB PLATELET PHERESIS,1501358,CDM,390,RC,P9034,HCPCS,outpatient,,,1405.53,843.32,,1054.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1124.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,434.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,299.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,299.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1054.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,302.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,340.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1264.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1054.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1054.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1054.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1054.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,287.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,287.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,163,1264.98,
BLOOD PLASMA TX,1502425,CDM,390,RC,P9059,HCPCS,outpatient,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,76.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,77.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,163,100,,,case rate,100% UHC case rate for outpatient setting,76.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,76.2,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,0.01,163,
CRYOPRECIPITATE,2500097,CDM,390,RC,P9012,HCPCS,outpatient,,,122.43,73.46,,91.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,75.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.09,163,
FFP,2500093,CDM,390,RC,P9017,HCPCS,outpatient,,,286.57,171.94,,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,111.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,61.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,87.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,257.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,214.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,85.47,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.72,257.91,
LEUKOCYTE REMOVAL FILTER FOR PACKE CELLS,2900004,CDM,390,RC,,,outpatient,,,52.45,31.47,,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.75,163,
LEUKOCYTE REMOVAL FILTER FOR PLATELET,2900003,CDM,390,RC,,,outpatient,,,344.76,206.86,,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,258.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.64,310.28,
MISC BLOOD ADMIN.,2900002,CDM,390,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,163,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163,163,
PACKED RBC (LEUKO REDUCED),1501340,CDM,390,RC,P9016,HCPCS,outpatient,,,243.08,145.85,,182.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,245.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,182.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,192.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,218.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,182.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.81,245.97,
PLTS PH,2500094,CDM,390,RC,P9034,HCPCS,outpatient,,,1582.44,949.46,,1186.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1265.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,434.16,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,337.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,337.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1186.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,340.64,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1424.2,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1186.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1186.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1186.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1186.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,333.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,163,1424.2,
PRBC LR,2500095,CDM,390,RC,P9016,HCPCS,outpatient,,,637.92,382.75,,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,245.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,135.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,192.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,574.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,130.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,130.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,130.71,574.13,
PRBC LR WASH,2500096,CDM,390,RC,P9016,HCPCS,outpatient,,,637.92,382.75,,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,245.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,135.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,192.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,574.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,478.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,130.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,130.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,130.71,574.13,
BLOOD ADMINISTRATION,2900001,CDM,391,RC,36430,HCPCS,outpatient,,,510.88,306.53,,383.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,408.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,466.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,108.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,109.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,365.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,459.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,383.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,104.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,104.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,104.68,1459.9,
REFERENCE CROSSMATCH,1500455,CDM,391,RC,86922,HCPCS,outpatient,,,307.61,184.57,,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,179.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,141.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,276.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,230.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163,100,,,case rate,100% UHC case rate for outpatient setting,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,138.31,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.03,276.85,
REFERENCE PHENOTYPE OTHER THAN ABO AND D,1501987,CDM,391,RC,86905,HCPCS,outpatient,,,57.09,34.25,,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,370.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.84,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,290.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,51.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,163,100,,,case rate,100% UHC case rate for outpatient setting,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,285.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.8,370.6,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",1600210,CDM,401,RC,77066,HCPCS,outpatient,,,327.27,196.36,,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,129.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,101.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,294.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,308.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.06,308.58,
MM ADDITIONAL VIEWS LT-SPOT COMP MAG,1600208,CDM,401,RC,77065LT,HCPCS,outpatient,,,255.42,153.25,,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,229.88,
MM ADDITIONAL VIEWS RT-SPOT COMP MAG,1600209,CDM,401,RC,77065RT,HCPCS,outpatient,,,255.42,153.25,,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,229.88,
MM MAMMO SCREENING CONVERTED TO DIAGNOST,1600206,CDM,401,RC,77066GG,HCPCS,outpatient,,,255.42,153.25,,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,229.88,
MM MAMMOGRAM DIAG UNILAT LT,1600144,CDM,401,RC,77065LT,HCPCS,outpatient,,,255.42,153.25,,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,229.88,
MM MAMMOGRAM DIAG UNILAT RT,1600142,CDM,401,RC,77065RT,HCPCS,outpatient,,,255.42,153.25,,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,229.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.71,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.34,229.88,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",1600143,CDM,401,RC,77066,HCPCS,outpatient,,,327.27,196.36,,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,129.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,101.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,294.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,308.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,99.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.06,308.58,
"Fine needle aspiration biopsy, including ultrasound guidance; first lesion",1620090,CDM,402,RC,10005,HCPCS,outpatient,,,1629.81,977.89,,1222.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1303.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,742.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,347.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,347.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,350.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,582.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1466.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1222.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1222.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1222.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1222.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,333.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1026.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,333.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,333.95,1466.83,
Ultrasound of abdomen with all areas scanned,1600121,CDM,402,RC,76700,HCPCS,outpatient,,,1495.56,897.34,,1121.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1196.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,318.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,318.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1121.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,321.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1346,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1121.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1121.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1121.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1121.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,306.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,306.44,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,1346,
Ultrasound of back wall of the abdomen with all areas viewed,1600122,CDM,402,RC,76770,HCPCS,outpatient,,,562.75,337.65,,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,506.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,506.48,
US AORTA SCREENING,1600751,CDM,402,RC,76706,HCPCS,outpatient,,,562.75,337.65,,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,506.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,506.48,
US BREAST UNILATERAL LT,1600168,CDM,402,RC,76641LT,HCPCS,outpatient,,,317.17,190.3,,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,285.45,
US BREAST UNILATERAL LTD LT,1600171,CDM,402,RC,76642LT,HCPCS,outpatient,,,317.17,190.3,,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,285.45,
US BREAST UNILATERAL LTD RT,1600173,CDM,402,RC,76642RT,HCPCS,outpatient,,,317.17,190.3,,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,285.45,
US BREAST UNILATERAL RT,1600165,CDM,402,RC,76641RT,HCPCS,outpatient,,,317.17,190.3,,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,285.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.59,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.99,285.45,
US CHEST,1600167,CDM,402,RC,76604,HCPCS,outpatient,,,317.17,190.3,,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,285.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.99,286.93,
US CYST ASPIRATION,1600537,CDM,402,RC,76942,HCPCS,outpatient,,,392.29,235.37,,294.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,83.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,294.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,353.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,294.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,294.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.38,353.06,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",1600185,CDM,402,RC,76882,HCPCS,outpatient,,,308.97,185.38,,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,278.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.31,286.93,
US EXTREMITY NON VASCULAR COMPLETE,1600754,CDM,402,RC,76881,HCPCS,outpatient,,,451.57,270.94,,338.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,96.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,338.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,406.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,338.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.53,406.41,
"Diagnostic ultrasound of an extremity excluding the bone, joints or vessels",1600755,CDM,402,RC,76882,HCPCS,outpatient,,,308.97,185.38,,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,247.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,278.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.31,286.93,
US FNA OR BIOPSY,1600300,CDM,402,RC,76942,HCPCS,outpatient,,,313.89,188.33,,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,282.5,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,1600123,CDM,402,RC,76705,HCPCS,outpatient,,,283.25,169.95,,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,60.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,254.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.04,286.93,
US GUIDANCE FOR AMNIOCENTESIS,1600207,CDM,402,RC,76946,HCPCS,outpatient,,,425.35,255.21,,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,382.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.15,382.82,
US GUIDANCE FOR NEEDLE PLACEMENT,1600400,CDM,402,RC,76942,HCPCS,outpatient,,,93.73,56.24,,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.21,84.36,
US GUIDE VASCULAR ACCESS,1600320,CDM,402,RC,76937,HCPCS,outpatient,,,72.4,43.44,,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,65.16,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,1600204,CDM,402,RC,76705,HCPCS,outpatient,,,482.16,289.3,,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,433.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,433.94,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,1600124,CDM,402,RC,76705,HCPCS,outpatient,,,283.25,169.95,,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,226.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,60.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,254.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.04,286.93,
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,1600133,CDM,402,RC,76805,HCPCS,outpatient,,,549.92,329.95,,412.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,117.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,412.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,494.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,412.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,412.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,112.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,112.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,494.93,
Ultrasound of single fetus,1600132,CDM,402,RC,76811,HCPCS,outpatient,,,709.73,425.84,,532.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,567.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,151.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,532.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,638.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,532.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,145.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,145.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,145.42,638.76,
US OB >14WKS DETAIL EACH ADDITIONAL GEST,1600579,CDM,402,RC,76812,HCPCS,outpatient,,,708.91,425.35,,531.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,567.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,531.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,638.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,531.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,531.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.26,638.02,
US OB >14WKS EACH ADDITIONAL GESTATION,1600583,CDM,402,RC,76810,HCPCS,outpatient,,,563.57,338.14,,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,507.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.48,507.21,
US OB 1ST TRIMESTER EACH ADDITIONAL GEST,1600569,CDM,402,RC,76802,HCPCS,outpatient,,,563.57,338.14,,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,507.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.48,507.21,
Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,1600131,CDM,402,RC,76801,HCPCS,outpatient,,,563.57,338.14,,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,120.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,507.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,507.21,
Ultrasound of fetus with limited views,1600203,CDM,402,RC,76815,HCPCS,outpatient,,,425.35,255.21,,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,90.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,382.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,87.15,382.82,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,1600125,CDM,402,RC,76705,HCPCS,outpatient,,,562.75,337.65,,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,506.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,506.48,
Complete ultrasound of the pelvis,1600156,CDM,402,RC,76856,HCPCS,outpatient,,,416.6,249.96,,312.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,312.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,374.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.36,374.94,
Complete ultrasound of the pelvis,1600126,CDM,402,RC,76856,HCPCS,outpatient,,,166.86,100.12,,125.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,150.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.19,286.93,
Ultrasound of back wall of the abdomen with limited areas viewed,1600127,CDM,402,RC,76775,HCPCS,outpatient,,,1084.59,650.75,,813.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,867.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,231.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,231.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,813.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,976.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,813.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,813.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,813.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,813.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,222.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,222.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,976.13,
Ultrasound of the scrotum,1600202,CDM,402,RC,76870,HCPCS,outpatient,,,776.12,465.67,,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,620.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,165.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,165.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,698.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,582.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,159.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,159.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,698.51,
Ultrasound of the pelvis through vagina,1600535,CDM,402,RC,76830,HCPCS,outpatient,,,710.28,426.17,,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,151.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,639.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,145.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,145.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94.01,639.25,
Transvaginal ultrasound of uterus,1600584,CDM,402,RC,76817,HCPCS,outpatient,,,710.28,426.17,,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,568.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,151.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,151.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,152.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,639.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,532.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,145.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,286.93,160,,,fee schedule,160% UHC fee schedule for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,145.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,639.25,
VEIN MAPPING,2810036,CDM,402,RC,G0365,HCPCS,outpatient,,,444.2,266.52,,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,355.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,94.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,399.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,222.1,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.02,399.78,
Mammography of both breasts-2 or more views,1600201,CDM,403,RC,77067,HCPCS,outpatient,,,629.33,377.6,,472,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,503.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,107.56,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,134.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,472,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,84.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,566.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,472,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,255.92,160,,,fee schedule,160% UHC fee schedule for outpatient setting,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.74,566.4,
Mammography of both breasts-2 or more views,1600157,CDM,403,RC,77067,HCPCS,outpatient,,,269.9,161.94,,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,107.56,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,57.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,84.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,242.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,255.92,160,,,fee schedule,160% UHC fee schedule for outpatient setting,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.3,255.92,
2ND HHN/AEROSOL SUBSEQUENT,2600095,CDM,410,RC,9464076,HCPCS,outpatient,,,408.41,245.05,,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.68,502,
AEROSOL CONT/HR,2600018,CDM,410,RC,,,outpatient,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.46,502,
ARTERIAL PUNCTURE,2600080,CDM,410,RC,36600,HCPCS,outpatient,,,144.2,86.52,,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,129.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,1459.9,
CATHETER ASP NASOTR,2600090,CDM,410,RC,31720,HCPCS,outpatient,,,373.76,224.26,,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,79.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,80.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,336.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.58,1459.9,
CHEST WALL MANI CUP/PERCUSS SUBSEQ,5294668,CDM,410,RC,94668,HCPCS,outpatient,,,237.64,142.58,,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,50.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,213.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,502,
"CHEST WALL MANI, CUP/PERCUSS INITIAL",5294667,CDM,410,RC,94667,HCPCS,outpatient,,,237.64,142.58,,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,50.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,213.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,502,
CNP INITIATION/MGMENT (NEGATIVE PRESS),5294662,CDM,410,RC,94662,HCPCS,outpatient,,,1029.07,617.44,,771.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,823.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,636.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,219.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,219.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,771.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,499.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,926.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,771.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,771.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,771.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,771.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,210.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,210.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,210.86,926.16,
CPAP INIT AND DAILY MANAGEMENT,2600069,CDM,410,RC,94660,HCPCS,outpatient,,,242.05,145.23,,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,217.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,502,
CPAP INITIATION/MGMENT (POSITIVE PRESS),5294660,CDM,410,RC,94660,HCPCS,outpatient,,,397.84,238.7,,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,358.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,502,
CPAP SUBSEQUENT DAILY,2600083,CDM,410,RC,94660,HCPCS,outpatient,,,242.05,145.23,,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,217.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,502,
CPAP TRIAL,2600101,CDM,410,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502,502,
CPT INITIAL,2600007,CDM,410,RC,94667,HCPCS,outpatient,,,251.88,151.13,,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,502,
CPT SUBSEQUENT,2600030,CDM,410,RC,94668,HCPCS,outpatient,,,144.2,86.52,,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,129.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,502,
"DEMO/EVAL USE OF AREO, NEB,MDI, IPPB",5294664,CDM,410,RC,94664,HCPCS,outpatient,,,397.84,238.7,,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,358.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,502,
EXTUBATION,2600055,CDM,410,RC,,,outpatient,,,97.25,58.35,,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.93,502,
FLUTTER DEVICE SUBSEQUENT USE DAILY,2600072,CDM,410,RC,94668,HCPCS,outpatient,,,137.41,82.45,,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,123.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,502,
FLUTTER DEVISE INIT DAILY,2600071,CDM,410,RC,94667,HCPCS,outpatient,,,251.88,151.13,,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,502,
HEART NEB TREATMENT,2600088,CDM,410,RC,94644,HCPCS,outpatient,,,144.2,86.52,,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,129.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,502,
HEART NEB TREATMENT EA ADD HOUR,2600089,CDM,410,RC,94645,HCPCS,outpatient,,,178.12,106.87,,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,142.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.5,502,
HEART NEB TREATMENT EA ADD HOUR 2,2600093,CDM,410,RC,94645,HCPCS,outpatient,,,144.7,86.82,,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.65,502,
HEART NEB TREATMENT EA ADD HOUR 3,2600094,CDM,410,RC,94645,HCPCS,outpatient,,,144.7,86.82,,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.65,502,
HHN TX/AEROSOL TX INITIAL,2600002,CDM,410,RC,94664,HCPCS,outpatient,,,242.05,145.23,,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,193.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,51.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,52.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,217.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.6,502,
HHN TX/AEROSOL TX SUBSEQUENT,2600020,CDM,410,RC,9464076,HCPCS,outpatient,,,387.28,232.37,,290.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,309.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,290.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,348.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,290.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,290.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.35,502,
HHN TX/AEROSOL TX SUBSEQUENT 2,2600091,CDM,410,RC,9464076,HCPCS,outpatient,,,373.76,224.26,,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.58,502,
HHN TX/AEROSOL TX SUBSEQUENT 3,2600092,CDM,410,RC,9464076,HCPCS,outpatient,,,373.76,224.26,,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,299.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,336.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.58,502,
"INHALTION TX (AERO, NEB, MDI,IPPB)",5294640,CDM,410,RC,94640,HCPCS,outpatient,,,397.84,238.7,,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,358.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,502,
INTUBATION,2600059,CDM,410,RC,31500,HCPCS,outpatient,,,339.9,203.94,,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,237.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,72.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,73.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,186.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,305.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.65,1459.9,
IPPB INITIAL TX,2600000,CDM,410,RC,94640,HCPCS,outpatient,,,408.41,245.05,,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,86.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,367.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,83.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,83.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,83.68,502,
IPPB TX SUBSEQUENT,2600019,CDM,410,RC,9464076,HCPCS,outpatient,,,408.41,245.05,,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,367.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.68,502,
MDI INSTRUCT INIT DAILY,2600073,CDM,410,RC,94664,HCPCS,outpatient,,,408.41,245.05,,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,86.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,86.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,367.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,83.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,83.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,83.68,502,
MECH CHEST WALL OSCILLATION PER SESSION,5294669,CDM,410,RC,94669,HCPCS,outpatient,,,397.84,238.7,,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,318.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,85.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,171.8,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,358.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,168.43,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.52,502,
T-PIECE TRIAL,2600102,CDM,410,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502,502,
"TX PROCED FOR IMPROVE RESP FXN O/O, 15 M",5200238,CDM,410,RC,G0238,HCPCS,outpatient,,,53.05,31.83,,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,47.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.87,502,
TX PROCED FOR STRENGTH/ENDURE 2 OR> INDV,5200239,CDM,410,RC,G0239,HCPCS,outpatient,,,71.08,42.65,,53.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,38.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,30.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,63.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.87,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.56,502,
"TX PROCED FOR STRENGTH/ENDURE O/O, 15 MI",5200237,CDM,410,RC,G0237,HCPCS,outpatient,,,53.05,31.83,,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.53,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,47.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.87,502,
USN FIRST HOUR,123475,CDM,410,RC,94644,HCPCS,outpatient,,,251.88,151.13,,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,502,
USN FIRST HOUR,2600005,CDM,410,RC,94644,HCPCS,outpatient,,,230.53,138.32,,172.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,172.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,207.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.24,502,
VENT INIT S/U and 1ST DAY,2600033,CDM,410,RC,94002,HCPCS,outpatient,,,625.21,375.13,,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,636.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,499.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,562.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.11,636.58,
VENTILATOR SUBSEQUENT DAY,2600034,CDM,410,RC,94003,HCPCS,outpatient,,,625.21,375.13,,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,500.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,636.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,499.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,562.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,468.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,489.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.11,636.58,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2600067,CDM,419,RC,97110,HCPCS,outpatient,,,93.15,55.89,,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,83.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.09,502,
APPLY NEUROSTIMULATOR,2800051,CDM,420,RC,64550,HCPCS,outpatient,,,76.22,45.73,,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,196,
BIOFEEDBACK-PERINEAL,2800053,CDM,420,RC,90912,HCPCS,outpatient,,,359.51,215.71,,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,76.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,42.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,323.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.42,323.56,
BIOFEEDBACK-PERINEAL,2800072,CDM,420,RC,90912,HCPCS,outpatient,,,359.51,215.71,,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,76.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,42.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,323.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,269.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,41.42,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.42,323.56,
BODY POS CURRENT STATUS,2840051,CDM,420,RC,G8981GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS CURRENT STATUS,2840052,CDM,420,RC,G8981GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS CURRENT STATUS,2840053,CDM,420,RC,G8981GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS CURRENT STATUS,2840054,CDM,420,RC,G8981GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS CURRENT STATUS,2840055,CDM,420,RC,G8981GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS CURRENT STATUS,2840056,CDM,420,RC,G8981GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS CURRENT STATUS,2840057,CDM,420,RC,G8981GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS D/C STATUS,2840065,CDM,420,RC,G8983GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS D/C STATUS,2840066,CDM,420,RC,G8983GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS D/C STATUS,2840067,CDM,420,RC,G8983GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS D/C STATUS,2840068,CDM,420,RC,G8983GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS D/C STATUS,2840069,CDM,420,RC,G8983GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS D/C STATUS,2840070,CDM,420,RC,G8983GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS D/C STATUS,2840071,CDM,420,RC,G8983GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS GOAL STATUS,2840058,CDM,420,RC,G8982GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS GOAL STATUS,2840059,CDM,420,RC,G8982GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS GOAL STATUS,2840060,CDM,420,RC,G8982GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS GOAL STATUS,2840061,CDM,420,RC,G8982GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS GOAL STATUS,2840062,CDM,420,RC,G8982GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS GOAL STATUS,2840063,CDM,420,RC,G8982GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BODY POS GOAL STATUS,2840064,CDM,420,RC,G8982GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CANALITH REPOSITIONING PROCEDURE PER DAY,2500373,CDM,420,RC,95992,HCPCS,outpatient,,,95.48,57.29,,71.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,35.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,85.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,71.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,35.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.56,196,
CARRY CURRENT STATUS,2840072,CDM,420,RC,G8984GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY CURRENT STATUS,2840073,CDM,420,RC,G8984GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY CURRENT STATUS,2840074,CDM,420,RC,G8984GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY CURRENT STATUS,2840075,CDM,420,RC,G8984GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY CURRENT STATUS,2840076,CDM,420,RC,G8984GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY CURRENT STATUS,2840077,CDM,420,RC,G8984GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY CURRENT STATUS,2840078,CDM,420,RC,G8984GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY D/C STATUS,2840086,CDM,420,RC,G8986GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY D/C STATUS,2840087,CDM,420,RC,G8986GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY D/C STATUS,2840088,CDM,420,RC,G8986GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY D/C STATUS,2840089,CDM,420,RC,G8986GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY D/C STATUS,2840090,CDM,420,RC,G8986GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY D/C STATUS,2840091,CDM,420,RC,G8986GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY D/C STATUS,2840092,CDM,420,RC,G8986GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY GOAL STATUS,2840079,CDM,420,RC,G8985GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY GOAL STATUS,2840080,CDM,420,RC,G8985GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY GOAL STATUS,2840081,CDM,420,RC,G8985GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY GOAL STATUS,2840082,CDM,420,RC,G8985GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY GOAL STATUS,2840083,CDM,420,RC,G8985GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY GOAL STATUS,2840084,CDM,420,RC,G8985GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARRY GOAL STATUS,2840085,CDM,420,RC,G8985GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CONTRAST BATH PER 15 MIN,2800044,CDM,420,RC,97034,HCPCS,outpatient,,,58.46,35.08,,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,13.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,52.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,196,
DEBRIDEMENT-15 MIN,2800025,CDM,420,RC,97602,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,1459.9,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2800026,CDM,420,RC,97110,HCPCS,outpatient,,,183.58,110.15,,137.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,137.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,165.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,137.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,137.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,196,
DEBRIDEMENT-45 MINUTES,2800027,CDM,420,RC,,,outpatient,,,235.76,141.46,,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.31,212.18,
DIATHERMY,2800009,CDM,420,RC,97024,HCPCS,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,196,
DIATHERMY-PRIMARY,2800008,CDM,420,RC,97024,HCPCS,outpatient,,,140.69,84.41,,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.91,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.85,196,
E-STIM UNATTENDED KX,2800127,CDM,420,RC,G0283,HCPCS,outpatient,,,46.44,27.86,,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,11.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,41.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,11.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.52,196,
One time use unattended,2800014,CDM,420,RC,97014,HCPCS,outpatient,,,74.16,44.5,,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,196,
One time use unattended,2800073,CDM,420,RC,97014,HCPCS,outpatient,,,46.17,27.7,,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,196,
One time use unattended,2800080,CDM,420,RC,97014,HCPCS,outpatient,,,46.17,27.7,,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,196,
One time use unattended,2800081,CDM,420,RC,97014,HCPCS,outpatient,,,46.17,27.7,,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,196,
Repeated application to one or more parts of the body,2800015,CDM,420,RC,97032,HCPCS,outpatient,,,62.01,37.21,,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,14.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,55.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,196,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2800024,CDM,420,RC,97110,HCPCS,outpatient,,,235.76,141.46,,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,50.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,212.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,212.18,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2800022,CDM,420,RC,97110,HCPCS,outpatient,,,216.3,129.78,,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,46.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,194.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,196,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2800023,CDM,420,RC,97110,HCPCS,outpatient,,,191.51,114.91,,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,40.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,172.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,196,
FUNCTIONAL CAPACITY EVALUATION PER/15MIN,2800062,CDM,420,RC,97750,HCPCS,outpatient,,,110.64,66.38,,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,99.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.67,196,
GAIT EVALUATION,2800092,CDM,420,RC,97001,HCPCS,outpatient,,,112.55,67.53,,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.06,196,
A type of physical therapy,2800019,CDM,420,RC,97116,HCPCS,outpatient,,,37.08,22.25,,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,33.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.6,196,
A type of physical therapy,2800020,CDM,420,RC,97116,HCPCS,outpatient,,,129.21,77.53,,96.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,96.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.48,196,
A type of physical therapy,2800021,CDM,420,RC,97116,HCPCS,outpatient,,,270.99,162.59,,203.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,216.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,57.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,243.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,203.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,243.89,
A type of physical therapy,2800125,CDM,420,RC,97116,HCPCS,outpatient,,,101.35,60.81,,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,91.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.77,196,
GROUP THERAPEUTIC PROC PER 15 MIN,2800046,CDM,420,RC,97150,HCPCS,outpatient,,,71.84,43.1,,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,17.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,196,
GROUP THERAPEUTIC PROC PER 15 MIN,2800075,CDM,420,RC,97150,HCPCS,outpatient,,,71.84,43.1,,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,17.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,196,
GROUP THERAPEUTIC PROC PER 15 MIN KX,2800131,CDM,420,RC,97150,HCPCS,outpatient,,,71.84,43.1,,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,17.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,196,
Use of external hot or cold packs,2800060,CDM,420,RC,97010,HCPCS,outpatient,,,49.17,29.5,,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.47,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,44.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,196,
Use of external hot or cold packs,2800003,CDM,420,RC,97010,HCPCS,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,196,
Light-based method to treat pain and inflammation,2800090,CDM,420,RC,97026,HCPCS,outpatient,,,18.58,11.15,,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.13,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,16.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,6.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.81,196,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",2800041,CDM,420,RC,97016,HCPCS,outpatient,,,54.91,32.95,,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,11.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.59,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,11.44,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,49.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,11.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.22,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.22,196,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,2800039,CDM,420,RC,97033,HCPCS,outpatient,,,86.6,51.96,,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,19.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,196,
Manipulation of 1 or more regions of the body,2800126,CDM,420,RC,97140,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,26.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,196,
Manipulation of 1 or more regions of the body,2800045,CDM,420,RC,97140,HCPCS,outpatient,,,250.29,150.17,,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,26.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,225.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.96,225.26,
Manipulation of 1 or more regions of the body,2800074,CDM,420,RC,97140,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,26.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,196,
Use of massage,2800007,CDM,420,RC,97124,HCPCS,outpatient,,,81.96,49.18,,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.79,196,
Use of massage,2800006,CDM,420,RC,97124,HCPCS,outpatient,,,130.04,78.02,,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,117.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.65,196,
MOBILITY CURRENT STATUS,2840030,CDM,420,RC,G8978GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY CURRENT STATUS,2840031,CDM,420,RC,G8978GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY CURRENT STATUS,2840032,CDM,420,RC,G8978GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY CURRENT STATUS,2840033,CDM,420,RC,G8978GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY CURRENT STATUS,2840034,CDM,420,RC,G8978GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY CURRENT STATUS,2840035,CDM,420,RC,G8978GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY CURRENT STATUS,2840036,CDM,420,RC,G8978GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY D/C STATUS,2840044,CDM,420,RC,G8980GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY D/C STATUS,2840045,CDM,420,RC,G8980GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY D/C STATUS,2840046,CDM,420,RC,G8980GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY D/C STATUS,2840047,CDM,420,RC,G8980GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY D/C STATUS,2840048,CDM,420,RC,G8980GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY D/C STATUS,2840049,CDM,420,RC,G8980GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY D/C STATUS,2840050,CDM,420,RC,G8980GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY GOAL STATUS,2840037,CDM,420,RC,G8979GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY GOAL STATUS,2840038,CDM,420,RC,G8979GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY GOAL STATUS,2840039,CDM,420,RC,G8979GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY GOAL STATUS,2840040,CDM,420,RC,G8979GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY GOAL STATUS,2840041,CDM,420,RC,G8979GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY GOAL STATUS,2840042,CDM,420,RC,G8979GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILITY GOAL STATUS,2840043,CDM,420,RC,G8979GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MOBILIZATION,2800042,CDM,420,RC,,,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.63,196,
MUSCLE TESTING HAND REPORT,2800036,CDM,420,RC,95832,HCPCS,outpatient,,,84.14,50.48,,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,196,
MUSCLE TESTING TOTAL EXCL HANDS,2800058,CDM,420,RC,95833,HCPCS,outpatient,,,132.22,79.33,,99.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,119,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,99.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.09,196,
MUSCLE TESTING TOTAL WITH HANDS,2800059,CDM,420,RC,95834,HCPCS,outpatient,,,159.81,95.89,,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.85,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.75,196,
MUSCLE TESTING-EXTR-TRUNK/REPORT,2800035,CDM,420,RC,95831,HCPCS,outpatient,,,98.62,59.17,,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.21,196,
A technique used by physical therapists to restore normal body movement patterns,2800124,CDM,420,RC,97112,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
A technique used by physical therapists to restore normal body movement patterns,2800040,CDM,420,RC,97112,HCPCS,outpatient,,,42.23,25.34,,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,38.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.65,196,
Use of external hot or cold packs,2800002,CDM,420,RC,97010,HCPCS,outpatient,,,138.5,83.1,,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,124.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,196,
Use of massage,2800016,CDM,420,RC,97124,HCPCS,outpatient,,,144.52,86.71,,108.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,130.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,196,
Use of massage,2800017,CDM,420,RC,97124,HCPCS,outpatient,,,43.71,26.23,,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,9.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,39.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.96,196,
ORTHOTIC FITTING/TRAINING PER 15 MIN,2800047,CDM,420,RC,97760,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,46.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
ORTHOTIC PROSTHETIC CHECKOUT 15 MIN,2800048,CDM,420,RC,97763,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,50.43,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,196,
OTHER PT CURRENT STATUS,2840114,CDM,420,RC,G8990GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT CURRENT STATUS,2840115,CDM,420,RC,G8990GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT CURRENT STATUS,2840116,CDM,420,RC,G8990GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT CURRENT STATUS,2840117,CDM,420,RC,G8990GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT CURRENT STATUS,2840118,CDM,420,RC,G8990GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT CURRENT STATUS,2840119,CDM,420,RC,G8990GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT CURRENT STATUS,2840120,CDM,420,RC,G8990GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT D/C STATUS,2840128,CDM,420,RC,G8992GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT D/C STATUS,2840129,CDM,420,RC,G8992GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT D/C STATUS,2840130,CDM,420,RC,G8992GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT D/C STATUS,2840131,CDM,420,RC,G8992GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT D/C STATUS,2840132,CDM,420,RC,G8992GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT D/C STATUS,2840133,CDM,420,RC,G8992GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT D/C STATUS,2840134,CDM,420,RC,G8992GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT GOAL STATUS,2840121,CDM,420,RC,G8991GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT GOAL STATUS,2840122,CDM,420,RC,G8991GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT GOAL STATUS,2840123,CDM,420,RC,G8991GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT GOAL STATUS,2840124,CDM,420,RC,G8991GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT GOAL STATUS,2840125,CDM,420,RC,G8991GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT GOAL STATUS,2840126,CDM,420,RC,G8991GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OTHER PT GOAL STATUS,2840127,CDM,420,RC,G8991GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
PARAFFIN BATH,2800013,CDM,420,RC,97018,HCPCS,outpatient,,,31.15,18.69,,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,5.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,28.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,196,
PARAFFIN BATH-PRIMARY,2800012,CDM,420,RC,97018,HCPCS,outpatient,,,140.69,84.41,,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.55,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,5.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,126.62,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,196,
PHYSICAL PERFORMANCE TEST,2800066,CDM,420,RC,97750,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
PHYSICAL PERFORMANCE TEST,2800084,CDM,420,RC,97750,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
PILATES CLASS MISC CHARGE,2800070,CDM,420,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
PILATES MAT EXERCIZE ONCE PER WEEK,2800068,CDM,420,RC,,,outpatient,,,80.32,48.19,,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.46,196,
PILATES MAT EXERCIZE TWICE PER WEEK,2800069,CDM,420,RC,,,outpatient,,,144.79,86.87,,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.83,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.67,196,
POST REHAB FITNESS PROGRAM,2800001,CDM,420,RC,,,outpatient,,,72.4,43.44,,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.83,196,
PROSTHETIC TRAINING,2800043,CDM,420,RC,97761,HCPCS,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,40.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,196,
PROSTHETIC TRAINING,2800076,CDM,420,RC,97761,HCPCS,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,40.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,196,
PT CONSULT 30MINUTES,2800029,CDM,420,RC,97001,HCPCS,outpatient,,,136.87,82.12,,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,196,
PT CONSULT 45 MINUTES,2800030,CDM,420,RC,97001,HCPCS,outpatient,,,235.76,141.46,,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,212.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,176.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.31,212.18,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2800032,CDM,420,RC,97110,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2800033,CDM,420,RC,97110,HCPCS,outpatient,,,232.47,139.48,,174.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,185.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,209.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,209.22,
PT SERVICE MISC,2800034,CDM,420,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
One time use unattended,2800111,CDM,420,RC,97014,HCPCS,outpatient,,,74.16,44.5,,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.2,196,
A type of physical therapy,2800117,CDM,420,RC,97116,HCPCS,outpatient,,,37.08,22.25,,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,33.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.6,196,
PTA-GROUP THERAPY,2800120,CDM,420,RC,97150,HCPCS,outpatient,,,21.63,12.98,,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,17.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,19.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.43,196,
PTA-GROUP THERAPY KX,2800132,CDM,420,RC,97150,HCPCS,outpatient,,,71.84,43.1,,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,17.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,196,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,2800113,CDM,420,RC,97033,HCPCS,outpatient,,,86.6,51.96,,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,19.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,196,
Manipulation of 1 or more regions of the body,2800119,CDM,420,RC,97140,HCPCS,outpatient,,,250.29,150.17,,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,200.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,26.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,225.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.96,225.26,
Use of massage,2800118,CDM,420,RC,97124,HCPCS,outpatient,,,81.96,49.18,,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,73.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.79,196,
A technique used by physical therapists to restore normal body movement patterns,2800116,CDM,420,RC,97112,HCPCS,outpatient,,,42.23,25.34,,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,8.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,38.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.65,196,
PTA-PARAFFIN BATH,2800112,CDM,420,RC,97018,HCPCS,outpatient,,,15.45,9.27,,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,5.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,13.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.17,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2800121,CDM,420,RC,97530,HCPCS,outpatient,,,214.24,128.54,,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,45.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,192.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,196,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2800115,CDM,420,RC,97110,HCPCS,outpatient,,,216.3,129.78,,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,46.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,194.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,44.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,196,
Form of decompression therapy of the spine,2800110,CDM,420,RC,97012,HCPCS,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,14.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,196,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",2800114,CDM,420,RC,97035,HCPCS,outpatient,,,50.54,30.32,,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,13.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,196,
RELAXATION MASSAGE PER 15/MIN,2800064,CDM,420,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
ROM/ MEASURE/ REPORT HAND,2800038,CDM,420,RC,95852,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,5.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.26,196,
ROM/ MEASURE/ REPORT-EXTR-TRUNK,2800037,CDM,420,RC,95851,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,7.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.55,196,
SELECTIVE DEBRIDEMENT,2800067,CDM,420,RC,97601,HCPCS,outpatient,,,257.07,154.24,,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,54.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.67,231.36,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",2800085,CDM,420,RC,97597,HCPCS,outpatient,,,417.97,250.78,,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,376.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.64,1459.9,
SELECTIVE DEBRIDEMENT > 20 SQ CM,2800086,CDM,420,RC,97598,HCPCS,outpatient,,,417.97,250.78,,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,376.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,376.17,
SELF CARE CURRENT STATUS,2840093,CDM,420,RC,G8987GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE CURRENT STATUS,2840094,CDM,420,RC,G8987GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE CURRENT STATUS,2840095,CDM,420,RC,G8987GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE CURRENT STATUS,2840096,CDM,420,RC,G8987GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE CURRENT STATUS,2840097,CDM,420,RC,G8987GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE CURRENT STATUS,2840098,CDM,420,RC,G8987GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE CURRENT STATUS,2840099,CDM,420,RC,G8987GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE D/C STATUS,2840107,CDM,420,RC,G8989GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE D/C STATUS,2840108,CDM,420,RC,G8989GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE D/C STATUS,2840109,CDM,420,RC,G8989GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE D/C STATUS,2840110,CDM,420,RC,G8989GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE D/C STATUS,2840111,CDM,420,RC,G8989GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE D/C STATUS,2840112,CDM,420,RC,G8989GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE D/C STATUS,2840113,CDM,420,RC,G8989GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE GOAL STATUS,2840100,CDM,420,RC,G8988GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE GOAL STATUS,2840101,CDM,420,RC,G8988GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE GOAL STATUS,2840102,CDM,420,RC,G8988GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE GOAL STATUS,2840103,CDM,420,RC,G8988GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE GOAL STATUS,2840104,CDM,420,RC,G8988GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE GOAL STATUS,2840105,CDM,420,RC,G8988GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SELF CARE GOAL STATUS,2840106,CDM,420,RC,G8988GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
Occupational therapy,2800065,CDM,420,RC,97535,HCPCS,outpatient,,,123.2,73.92,,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,31.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,196,
SUBS PT CURRENT STATUS,2840135,CDM,420,RC,G8993GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT CURRENT STATUS,2840136,CDM,420,RC,G8993GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT CURRENT STATUS,2840137,CDM,420,RC,G8993GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT CURRENT STATUS,2840138,CDM,420,RC,G8993GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT CURRENT STATUS,2840139,CDM,420,RC,G8993GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT CURRENT STATUS,2840140,CDM,420,RC,G8993GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT CURRENT STATUS,2840141,CDM,420,RC,G8993GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT D/C STATUS,2840149,CDM,420,RC,G8995GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT D/C STATUS,2840150,CDM,420,RC,G8995GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT D/C STATUS,2840151,CDM,420,RC,G8995GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT D/C STATUS,2840152,CDM,420,RC,G8995GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT D/C STATUS,2840153,CDM,420,RC,G8995GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT D/C STATUS,2840154,CDM,420,RC,G8995GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT D/C STATUS,2840155,CDM,420,RC,G8995GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT GOAL STATUS,2840142,CDM,420,RC,G8994GPCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT GOAL STATUS,2840143,CDM,420,RC,G8994GPCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT GOAL STATUS,2840144,CDM,420,RC,G8994GPCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT GOAL STATUS,2840145,CDM,420,RC,G8994GPCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT GOAL STATUS,2840146,CDM,420,RC,G8994GPCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT GOAL STATUS,2840147,CDM,420,RC,G8994GPCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SUBS PT GOAL STATUS,2840148,CDM,420,RC,G8994GPCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
THER ACTIVITY FOR POSTURE TRAINING,2800079,CDM,420,RC,9753059,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2800050,CDM,420,RC,97530,HCPCS,outpatient,,,214.24,128.54,,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,45.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,192.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,43.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2800077,CDM,420,RC,97530,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2800123,CDM,420,RC,97530,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2800082,CDM,420,RC,97530,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2800083,CDM,420,RC,97530,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2800061,CDM,420,RC,97530,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2800122,CDM,420,RC,97110,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
Use of massage,2800063,CDM,420,RC,97124,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,196,
Form of decompression therapy of the spine,2800011,CDM,420,RC,97012,HCPCS,outpatient,,,62.01,37.21,,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,14.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,55.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,196,
Form of decompression therapy of the spine,2800010,CDM,420,RC,97012,HCPCS,outpatient,,,154.62,92.77,,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,14.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.89,196,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",2800005,CDM,420,RC,97035,HCPCS,outpatient,,,50.54,30.32,,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,13.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,196,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",2800004,CDM,420,RC,97035,HCPCS,outpatient,,,138.5,83.1,,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,13.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,124.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.72,196,
UNLISTED MODALITY PER 15 MIN,2800055,CDM,420,RC,97039,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,196,
UNLISTED THERAPEUTIC PROC 15MINUTES,2800031,CDM,420,RC,97139,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,196,
WHEELCHAIR MNGMT TRAINING 15 MIN,2800049,CDM,420,RC,97542,HCPCS,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,30.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,196,
WHIRLPOOL,2800018,CDM,420,RC,97022,HCPCS,outpatient,,,66.93,40.16,,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,16.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,60.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,196,
WHIRLPOOL,2800091,CDM,420,RC,97022,HCPCS,outpatient,,,66.93,40.16,,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,16.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,60.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,196,
WORK CONDITIONING ADDITIONAL HOUR,2800057,CDM,420,RC,97546,HCPCS,outpatient,,,120.48,72.29,,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,108.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.69,196,
WORK CONDITIONING INITIAL 2HRS,2800056,CDM,420,RC,97545,HCPCS,outpatient,,,321.54,192.92,,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,257.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,289.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,241.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.88,289.39,
CANALITH REPOSITIONING,2840282,CDM,424,RC,95992GP,HCPCS,outpatient,,,158.44,95.06,,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.46,196,
PATIENT EVALUATION,2800028,CDM,424,RC,97001,HCPCS,outpatient,,,326.45,195.87,,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,293.81,
PT EVAL HI LVL KX,2800130,CDM,424,RC,97163,HCPCS,outpatient,,,234.12,140.47,,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,210.71,
PT EVAL LI,2800100,CDM,424,RC,97161,HCPCS,outpatient,,,437.75,262.65,,328.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,93.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,328.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,393.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.69,393.98,
PT EVAL LII,2800101,CDM,424,RC,97162,HCPCS,outpatient,,,123.6,74.16,,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,111.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.33,196,
PT EVAL LIII,2800102,CDM,424,RC,97163,HCPCS,outpatient,,,234.12,140.47,,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,210.71,
PT EVAL LOW LVL KX,2800128,CDM,424,RC,97161,HCPCS,outpatient,,,234.12,140.47,,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,210.71,
PT EVAL MOD LVL KX,2800129,CDM,424,RC,97162,HCPCS,outpatient,,,234.12,140.47,,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,210.71,
PT RE-EVAL,2800103,CDM,424,RC,97164,HCPCS,outpatient,,,157.63,94.58,,118.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,33.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,118.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,67.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,141.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,118.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,66.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.3,196,
PT REEVALUATION,2800054,CDM,424,RC,97002,HCPCS,outpatient,,,188.77,113.26,,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,196,
PT REEVALUATION 59,2800071,CDM,424,RC,97002,HCPCS,outpatient,,,188.77,113.26,,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,196,
APPLY FINGER SPLINT STATIC,2820005,CDM,430,RC,29130,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,1459.9,
APPLY LONG LEG SPLINT,2820006,CDM,430,RC,29505,HCPCS,outpatient,,,205.43,123.26,,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,43.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,44.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,184.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.09,1459.9,
APPLY SHORT ARM SPLINT DYNAMIC,2820004,CDM,430,RC,29126,HCPCS,outpatient,,,195.06,117.04,,146.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,41.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,41.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,175.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,146.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.97,1459.9,
APPLY SHORT ARM SPLINT STATIC,2820003,CDM,430,RC,29125,HCPCS,outpatient,,,154.08,92.45,,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,32.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,33.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,138.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.57,1459.9,
APPLY SHORT LEG SPLINT,2820007,CDM,430,RC,29515,HCPCS,outpatient,,,174.56,104.74,,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,37.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,37.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,157.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.77,1459.9,
CHECK OUT FOR ORTHO/PROSTH USE EA 15 MIN,2820025,CDM,430,RC,97763,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,50.43,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,196,
CHECK OUT FOR ORTHO/PROSTH USE EA 15 MIN,2820042,CDM,430,RC,97763,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,64.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,50.43,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,49.44,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,196,
COMM/WORK REINTERGRATION EA 15 MIN,2820023,CDM,430,RC,97537,HCPCS,outpatient,,,112.27,67.36,,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,30.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,101.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23,196,
CONTRAST BATH PER 15 MIN,2820052,CDM,430,RC,97034,HCPCS,outpatient,,,58.46,35.08,,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,13.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,52.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.98,196,
DEVELOPMENT OF COGNITIVE SKILLS 15 MIN,2820026,CDM,430,RC,97129,HCPCS,outpatient,,,92.34,55.4,,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,21.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,22.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,83.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,21.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.76,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,196,
One time use unattended,2820047,CDM,430,RC,97014,HCPCS,outpatient,,,46.17,27.7,,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,196,
One time use unattended,2820048,CDM,430,RC,97014,HCPCS,outpatient,,,46.17,27.7,,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.46,196,
Repeated application to one or more parts of the body,2820051,CDM,430,RC,97032,HCPCS,outpatient,,,62.01,37.21,,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,14.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,55.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.71,196,
Use of external hot or cold packs,2820053,CDM,430,RC,97010,HCPCS,outpatient,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.51,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,25.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.77,196,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,2820049,CDM,430,RC,97033,HCPCS,outpatient,,,86.6,51.96,,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,19.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.74,196,
MANUAL MUSCLE TEST HAND,2820009,CDM,430,RC,95832,HCPCS,outpatient,,,84.14,50.48,,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.24,196,
Manipulation of 1 or more regions of the body,2820043,CDM,430,RC,97140,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,26.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.33,196,
Manipulation of 1 or more regions of the body,2820044,CDM,430,RC,97140,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,26.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
Use of massage,2820017,CDM,430,RC,97124,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,196,
Use of massage,2820036,CDM,430,RC,97124,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.89,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,196,
NEUROBEHAVIORAL STATUS EXAM PER HOUR,2820012,CDM,430,RC,96116,HCPCS,outpatient,,,262.53,157.52,,196.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,210.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,236.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,196.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,196.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.79,320.22,
A technique used by physical therapists to restore normal body movement patterns,2820016,CDM,430,RC,97112,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
A technique used by physical therapists to restore normal body movement patterns,2820035,CDM,430,RC,97112,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
ORTHOTIC FITTIN/TRAIN UPPER/LOW EXT 15M,2820019,CDM,430,RC,97760,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,46.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
ORTHOTIC FITTIN/TRAIN UPPER/LOW EXT 15M,2820038,CDM,430,RC,97760,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,46.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.35,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
PARAFFIN BATH,2820013,CDM,430,RC,97018GO,HCPCS,outpatient,,,31.15,18.69,,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.38,196,
PARAFFIN BATH,2820045,CDM,430,RC,97018,HCPCS,outpatient,,,31.15,18.69,,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.97,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,5.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,28.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.36,196,
PHYSICAL PERFOMANCE TEST,2820033,CDM,430,RC,97750,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
PHYSICAL PERFORMANCE TEST,2820032,CDM,430,RC,97750,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,41.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,32.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
PROSTHETIC TRAINING EA 15 MIN,2820020,CDM,430,RC,97761,HCPCS,outpatient,,,107.9,64.74,,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.18,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,40.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,39.37,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.11,196,
ROM MEASUREMENTS EA EXTREMITY W/REPORT,2820010,CDM,430,RC,95851,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,7.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.55,196,
ROM MEASUREMENTS EA EXTREMITY W/REPORT,2820030,CDM,430,RC,95851,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,7.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.55,196,
ROM MEASUREMENTS HAND W/REPORT,2820011,CDM,430,RC,95852,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,5.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.26,196,
ROM MEASUREMENTS HAND W/REPORT,2820031,CDM,430,RC,95852,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,5.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.26,196,
Occupational therapy,2820022,CDM,430,RC,97535,HCPCS,outpatient,,,123.2,73.92,,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,31.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,196,
Occupational therapy,2820040,CDM,430,RC,97535,HCPCS,outpatient,,,123.2,73.92,,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.56,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,26.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,31.73,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,110.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,31.11,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,25.24,196,
SENSORY INTERGRATION 15 MIN,2820028,CDM,430,RC,97533GO,HCPCS,outpatient,,,106,63.6,,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.72,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2820021,CDM,430,RC,97530,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",2820039,CDM,430,RC,97530,HCPCS,outpatient,,,120.2,72.12,,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,35.65,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,34.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.63,196,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2820015,CDM,430,RC,97110,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",2820034,CDM,430,RC,97110,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,28.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,28.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.24,196,
THERAPEUTIC PROC. GROUP EA 15 MIN,2820018,CDM,430,RC,97150,HCPCS,outpatient,,,71.84,43.1,,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,17.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,196,
THERAPEUTIC PROC. GROUP EA 15 MIN,2820037,CDM,430,RC,97150,HCPCS,outpatient,,,71.84,43.1,,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,17.37,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,64.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.72,196,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",2820050,CDM,430,RC,97035,HCPCS,outpatient,,,50.54,30.32,,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,13.99,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,45.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.72,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.36,196,
UNLISTED MODALITY,2820014,CDM,430,RC,97039GO,HCPCS,outpatient,,,82.24,49.34,,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.85,196,
UNLISTED THERAPEUTIC PROCEDURE,2820027,CDM,430,RC,97139GO,HCPCS,outpatient,,,108.99,65.39,,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,87.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.33,196,
WHEELCHAIR MANAGEMENT TRAINING EA 15 MIN,2820024,CDM,430,RC,97542,HCPCS,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,30.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,196,
WHEELCHAIR MANAGEMENT TRAINING EA 15 MIN,2820041,CDM,430,RC,97542,HCPCS,outpatient,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,39.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,30.95,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,92.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.05,196,
WHIRLPOOL,2820046,CDM,430,RC,97022,HCPCS,outpatient,,,66.93,40.16,,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,16.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,60.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.71,196,
<=DIET ORDER=>,7700000,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=ER DIET ORDER=>,7700010,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=FOOD BEVERAGE PREFERENCE=>,7700001,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=GUEST TRAY CHARGEABLE=>,7700008,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=GUEST TRAY=>,7700003,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=MISC ITEM ORDER=>,7700004,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=NUTRITIONAL ASSESSMENT=>,7700007,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=SPECIAL INSTRUCTIONS=>,7700002,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=SUPPLEMENTAL FEEDING=>,7700011,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
<=TUBE FEEDING=>,7700006,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
1200 CAL ADA DIET,7700012,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
1500 CAL ADA DIET,7700013,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
1800 CAL ADA DIET,7700014,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
2000 CAL ADA DIET,7700015,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
2200 CAL ADA DIET,7700016,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
APPLY NEUROSTIMULATOR,2820054,CDM,431,RC,64550,HCPCS,outpatient,,,76.22,45.73,,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.62,196,
BLAND DIET,7700026,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
BRAT DIET,7700032,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CARDIAC DIET,7700023,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
CLEAR LIQUIDS DIET,7700022,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
EXT MANUAL MUSCLE TEST (EXCL HAND),2820008,CDM,431,RC,95831,HCPCS,outpatient,,,98.62,59.17,,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,88.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.21,196,
FLUID RESTRICTED DIET,7700024,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
FULL LIQUIDS DIET,7700021,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
HIGH FIBER DIET,7700034,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
LOW CHOLESTEROL /LOW FAT DIET,7700030,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
LOW CHOLESTEROL DIET,7700029,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
LOW FIBER DIET,7700033,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
LOW SODIUM DIET,7700020,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
NO CONCENTRATED SWEETS DIET,7700028,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
NPO,7700018,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
NPO EXCEPT FOR MEDS,7700019,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
REGULAR DIET,7700017,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
RENAL DIET,7700025,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
SOFT DIET,7700027,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TODDLERS DIET,7700031,CDM,431,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
OCCUPATIONAL THERAPY EVAL,2820001,CDM,434,RC,97003,HCPCS,outpatient,,,326.45,195.87,,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.19,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,293.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.89,293.81,
OCCUPATIONAL THERAPY RE-EVAL,2820002,CDM,434,RC,97004,HCPCS,outpatient,,,188.77,113.26,,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,196,
OT EVAL LI,2820100,CDM,434,RC,97165,HCPCS,outpatient,,,234.12,140.47,,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,210.71,
OT EVAL LII,2820101,CDM,434,RC,97166,HCPCS,outpatient,,,234.12,140.47,,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,210.71,
OT EVAL LIII,2820102,CDM,434,RC,97167,HCPCS,outpatient,,,234.12,140.47,,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.74,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,97.87,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,210.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,175.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,95.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.97,210.71,
OT RE-EVAL,2820103,CDM,434,RC,97168,HCPCS,outpatient,,,149.16,89.5,,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,65.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.61,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,67.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,134.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,65.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.85,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.56,196,
OT REEVAL WITH TREATMENT,2820029,CDM,434,RC,97004,HCPCS,outpatient,,,188.77,113.26,,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,151.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,169.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.68,196,
ASSESSMENT OF APHASIA W/INTER AND REPORT,2830009,CDM,440,RC,96105GN,HCPCS,outpatient,,,312.8,187.68,,234.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,234.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,234.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.09,281.52,
AURAL REHAB FOLLOWING COCHLEAR IMPLANT,2830004,CDM,440,RC,92510,HCPCS,outpatient,,,564.94,338.96,,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,451.95,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,508.45,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,115.76,508.45,
DEV COGNITIVE SKILLS 15 MIN,2830015,CDM,440,RC,97129GN,HCPCS,outpatient,,,108.18,64.91,,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.17,196,
DEVELOPMENTAL TEST ADM 1ST HR,2830019,CDM,440,RC,96112,HCPCS,outpatient,,,382.73,229.64,,287.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,81.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,287.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,344.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,287.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.42,344.46,
DEVELOPMENTAL TEST ADM EA ADDNL 30 MIN,2830020,CDM,440,RC,96113,HCPCS,outpatient,,,168.83,101.3,,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.59,196,
DEVELOPMENTAL TESTING W/INTER EXTENDED,2830011,CDM,440,RC,96111GN,HCPCS,outpatient,,,551.82,331.09,,413.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,117.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,117.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,413.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,118.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,496.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,413.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,413.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,113.07,496.64,
DEVELOPMENTAL TESTING W/INTER LIMITED/,2830010,CDM,440,RC,96110GN,HCPCS,outpatient,,,205.43,123.26,,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,164.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,43.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,184.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,154.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.09,196,
Repeated application to one or more parts of the body,2830014,CDM,440,RC,97032,HCPCS,outpatient,,,78.4,47.04,,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,16.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,14.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,70.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.89,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.89,196,
MISC SPEECH THERAPY,2830012,CDM,440,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
MODIFY ORAL SPEECH DEVICE,2830008,CDM,440,RC,92598,HCPCS,outpatient,,,410.87,246.52,,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.19,369.78,
NEUROMUSCULAR RE EDUC PER 15 MIN,2830016,CDM,440,RC,97112GN,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.24,196,
Therapy for speech or hearing,2830002,CDM,440,RC,92507,HCPCS,outpatient,,,260.89,156.53,,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,56.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,74.96,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,234.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,195.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.46,234.8,
Therapy for speech or hearing,2830018,CDM,440,RC,92507,HCPCS,outpatient,,,353.76,212.26,,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,283.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,95.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,75.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,74.96,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,318.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,72.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,72.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,73.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,72.49,318.38,
SPEECH THERAPY/GROUP,2830003,CDM,440,RC,92508,HCPCS,outpatient,,,120.48,72.29,,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,96.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,22.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.66,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,23.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,108.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,22.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,22.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.57,196,
TERMINATED,2840156,CDM,440,RC,G8996GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840157,CDM,440,RC,G8996GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840158,CDM,440,RC,G8996GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840159,CDM,440,RC,G8996GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840160,CDM,440,RC,G8996GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840161,CDM,440,RC,G8996GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840162,CDM,440,RC,G8996GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840163,CDM,440,RC,G8997GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840164,CDM,440,RC,G8997GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840165,CDM,440,RC,G8997GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840166,CDM,440,RC,G8997GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840167,CDM,440,RC,G8997GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840168,CDM,440,RC,G8997GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840169,CDM,440,RC,G8997GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840170,CDM,440,RC,G8998GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840171,CDM,440,RC,G8998GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840172,CDM,440,RC,G8998GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840173,CDM,440,RC,G8998GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840174,CDM,440,RC,G8998GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840175,CDM,440,RC,G8998GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840176,CDM,440,RC,G8998GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840177,CDM,440,RC,G8999GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840178,CDM,440,RC,G8999GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840179,CDM,440,RC,G8999GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840180,CDM,440,RC,G8999GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840181,CDM,440,RC,G8999GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840182,CDM,440,RC,G8999GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840183,CDM,440,RC,G8999GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840184,CDM,440,RC,G9186GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840185,CDM,440,RC,G9186GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840186,CDM,440,RC,G9186GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840187,CDM,440,RC,G9186GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840188,CDM,440,RC,G9186GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840189,CDM,440,RC,G9186GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840190,CDM,440,RC,G9186GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840191,CDM,440,RC,G9158GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840192,CDM,440,RC,G9158GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840193,CDM,440,RC,G9158GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840194,CDM,440,RC,G9158GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840195,CDM,440,RC,G9158GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840196,CDM,440,RC,G9158GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840197,CDM,440,RC,G9158GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840198,CDM,440,RC,G9159GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840199,CDM,440,RC,G9159GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840200,CDM,440,RC,G9159GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840201,CDM,440,RC,G9159GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840202,CDM,440,RC,G9159GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840203,CDM,440,RC,G9159GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840204,CDM,440,RC,G9159GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840205,CDM,440,RC,G9160GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840206,CDM,440,RC,G9160GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840207,CDM,440,RC,G9160GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840208,CDM,440,RC,G9160GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840209,CDM,440,RC,G9160GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840210,CDM,440,RC,G9160GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840211,CDM,440,RC,G9160GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840212,CDM,440,RC,G9161GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840213,CDM,440,RC,G9161GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840214,CDM,440,RC,G9161GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840215,CDM,440,RC,G9161GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840216,CDM,440,RC,G9161GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840217,CDM,440,RC,G9161GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840218,CDM,440,RC,G9161GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840219,CDM,440,RC,G9162GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840220,CDM,440,RC,G9162GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840221,CDM,440,RC,G9162GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840222,CDM,440,RC,G9162GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840223,CDM,440,RC,G9162GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840224,CDM,440,RC,G9162GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840225,CDM,440,RC,G9162GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840226,CDM,440,RC,G9163GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840227,CDM,440,RC,G9163GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840228,CDM,440,RC,G9163GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840229,CDM,440,RC,G9163GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840230,CDM,440,RC,G9163GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840231,CDM,440,RC,G9163GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840232,CDM,440,RC,G9163GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840233,CDM,440,RC,G9164GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840234,CDM,440,RC,G9164GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840235,CDM,440,RC,G9164GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840236,CDM,440,RC,G9164GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840237,CDM,440,RC,G9164GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840238,CDM,440,RC,G9164GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840239,CDM,440,RC,G9164GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840240,CDM,440,RC,G9171GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840241,CDM,440,RC,G9171GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840242,CDM,440,RC,G9171GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840243,CDM,440,RC,G9171GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840244,CDM,440,RC,G9171GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840245,CDM,440,RC,G9171GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840246,CDM,440,RC,G9171GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840247,CDM,440,RC,G9172GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840248,CDM,440,RC,G9172GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840249,CDM,440,RC,G9172GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840250,CDM,440,RC,G9172GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840251,CDM,440,RC,G9172GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840252,CDM,440,RC,G9172GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840253,CDM,440,RC,G9172GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840254,CDM,440,RC,G9173GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840255,CDM,440,RC,G9173GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840256,CDM,440,RC,G9173GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840257,CDM,440,RC,G9173GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840258,CDM,440,RC,G9173GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840259,CDM,440,RC,G9173GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840260,CDM,440,RC,G9173GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840261,CDM,440,RC,G9174GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840262,CDM,440,RC,G9174GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840263,CDM,440,RC,G9174GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840264,CDM,440,RC,G9174GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840265,CDM,440,RC,G9174GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840266,CDM,440,RC,G9174GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840267,CDM,440,RC,G9174GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840268,CDM,440,RC,G9175GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840269,CDM,440,RC,G9175GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840270,CDM,440,RC,G9175GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840271,CDM,440,RC,G9175GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840272,CDM,440,RC,G9175GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840273,CDM,440,RC,G9175GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840274,CDM,440,RC,G9175GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840275,CDM,440,RC,G9176GNCH,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840276,CDM,440,RC,G9176GNCI,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840277,CDM,440,RC,G9176GNCJ,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840278,CDM,440,RC,G9176GNCK,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840279,CDM,440,RC,G9176GNCL,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840280,CDM,440,RC,G9176GNCM,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
TERMINATED,2840281,CDM,440,RC,G9176GNCN,HCPCS,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
THERAPUTIC EXERCISE X 15 MIN,2830013,CDM,440,RC,97110GN,HCPCS,outpatient,,,118.3,70.98,,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.24,196,
TREATMENT OF SWALLOWING DYSFUNCTION/,2830006,CDM,440,RC,92526GN,HCPCS,outpatient,,,349.67,209.8,,262.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,74.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,262.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.18,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,314.7,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,262.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.65,314.7,
1,8000000,CDM,444,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196,196,
EVAL OF SWALLOWING AND ORAL FUNCTION,2830005,CDM,444,RC,92610GN,HCPCS,outpatient,,,558.11,334.87,,418.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,118.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,118.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,418.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,418.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,418.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.36,502.3,
MOTION FLUROSCOPIC EVAL OF SWALLOWING,2830017,CDM,444,RC,92611GN,HCPCS,outpatient,,,471.78,283.07,,353.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,100.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,353.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,424.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,353.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,353.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.67,424.6,
ORAL SPEECH DEVICE EVALUATION,2830007,CDM,444,RC,92597,HCPCS,outpatient,,,410.87,246.52,,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,69.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.9,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,87.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,70.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,369.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,84.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,69.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,84.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.15,369.78,
Evaluation of speech sound production with evaluation of language comprehension,2830001,CDM,444,RC,92523,HCPCS,outpatient,,,568.5,341.1,,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,218.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,284.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,121.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,121.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,223.02,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,511.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,426.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,218.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,196,100,,,case rate,100% UHC case rate for outpatient setting,218.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,218.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,116.49,511.65,
ABD PARACENTESIS W/GUIDE,2500347,CDM,450,RC,49083,HCPCS,outpatient,,,1880.98,1128.59,,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,943.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,404.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,740.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1692.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1185.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,1692.88,
ANOSCOPY W/FB REMOVAL,2500346,CDM,450,RC,46608,HCPCS,outpatient,,,1843.84,1106.3,,1382.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1475.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,950.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,392.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,392.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,396.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,745.58,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1659.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1382.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1382.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1382.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1382.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,377.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1161.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,377.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,377.8,1659.46,
APP CAST ELBOW TO FINGER,2500294,CDM,450,RC,29075,HCPCS,outpatient,,,560.16,336.1,,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,274.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,120.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,215.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,504.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,352.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,1459.9,
APP CAST SHOULDER TO HAND,2500293,CDM,450,RC,29065,HCPCS,outpatient,,,560.16,336.1,,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,274.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,120.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,215.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,504.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,352.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,1459.9,
APP FINGER SPLINT,2500297,CDM,450,RC,29130,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
APP LONG ARM SPLINT,2500295,CDM,450,RC,29105,HCPCS,outpatient,,,327.82,196.69,,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,70.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,295.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,206.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,1459.9,
APP LONG LEG CAST,2500302,CDM,450,RC,29345,HCPCS,outpatient,,,581.37,348.82,,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,274.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,123.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,124.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,215.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,523.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,366.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.12,1459.9,
APP LONG LEG SPLINT,2500304,CDM,450,RC,29505,HCPCS,outpatient,,,327.82,196.69,,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,70.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,295.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,206.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,1459.9,
APP SHORT ARM SPLINT STATIC,2500296,CDM,450,RC,29125,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
APP SHORT LEG CAST,2500303,CDM,450,RC,29405,HCPCS,outpatient,,,581.37,348.82,,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,274.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,123.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,124.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,215.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,523.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,436.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,366.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,119.12,1459.9,
APP SHORT LEG SPLINT,2500305,CDM,450,RC,29515,HCPCS,outpatient,,,327.82,196.69,,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,70.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,295.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,206.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,1459.9,
ARTERIAL CATHERIZATION PERCUTANEOUS,2500329,CDM,450,RC,36620,HCPCS,outpatient,,,367.07,220.24,,275.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,293.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,275.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,330.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,275.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,275.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,231.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.21,330.36,
ARTHROCENTESIS INTERMED JNT W/GUIDE,2500202,CDM,450,RC,20606,HCPCS,outpatient,,,1474.65,884.79,,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1179.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,314.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,317.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1327.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,929.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,1459.9,
Draining or injecting medication into a large joint/bursa without ultrasound,2500201,CDM,450,RC,20605,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
Draining or injecting medication into a major joint/bursa without ultrasound,2500204,CDM,450,RC,20610,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
Draining or injecting medication into a major joint/bursa without ultrasound,2500203,CDM,450,RC,20610,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
ARTHROCENTESIS SMALL JNT W/GUIDE,2500200,CDM,450,RC,20604,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
Draining or injecting medication into a small joint/bursa without ultrasound,2500199,CDM,450,RC,20600,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
Separation and removal of the entire nail plate or a portion of nail plate,2500144,CDM,450,RC,11730,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
AVULTION NAIL PLATE EA ADDNL,2500145,CDM,450,RC,11732,HCPCS,outpatient,,,79.57,47.74,,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.3,71.61,
BURN DRESSING,2500079,CDM,450,RC,,,outpatient,,,417.97,250.78,,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2053.58,100,,,case rate,100% Anthem case rate for outpatient setting,89.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,376.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,263.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.64,2053.58,
CARDIOVERSION ELECTIVE EXTERNAL,2500380,CDM,450,RC,92960,HCPCS,outpatient,,,1305.97,783.58,,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,672.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,278.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,278.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,527.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1175.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,822.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,1175.37,
CARDIOVERSION ELECTIVE INTERNAL,2500371,CDM,450,RC,92961,HCPCS,outpatient,,,1305.97,783.58,,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,672.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,278.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,278.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,527.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1175.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,822.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,1175.37,
CLSD TX CLAVICULAR FX W/MANI,2500208,CDM,450,RC,23505,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSD TX CLAVICULAR FX W/O MANI,2500207,CDM,450,RC,23500,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED SUPRA/TRANS HUMERAL FX W/MANI,2500218,CDM,450,RC,24535,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED SUPRA/TRANS HUMERAL FX W/O MANI,2500217,CDM,450,RC,24530,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX ANKLE DISLO W/ANESTH,2500281,CDM,450,RC,27842,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX ANKLE DISLO W/O ANESTH,2500280,CDM,450,RC,27840,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX BIMALLEOLAR ANKLE FX W/MANI,2500275,CDM,450,RC,27810,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX BIMALLEOLAR ANKLE FX W/O MANI,2500274,CDM,450,RC,27808,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX DIS RAD FX/EPI SEP W/MANI,2500232,CDM,450,RC,25605,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX DIS RAD FX/EPI SEP W/O MANI,2500233,CDM,450,RC,25600,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX DIST PHAL FX FNGR/THUMB W/MANI,2500244,CDM,450,RC,26755,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX DIST PHAL FX FNGR/THUMB W/O MAN,2500243,CDM,450,RC,26750,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX DISTAL FIBULAR FX W/MANI,2500273,CDM,450,RC,27788,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX DISTAL FIBULAR FX W/O MANI,2500272,CDM,450,RC,27786,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
"CLSED TX FEMORAL FX DISTAL, MEDIAL, LAT",2500258,CDM,450,RC,27508,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
"CLSED TX FEMORAL FX DISTAL, MEDIAL, LAT",2500259,CDM,450,RC,27510,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX FEMORAL SHAFT FX W/MANI,2500256,CDM,450,RC,27502,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX FEMORAL SHAFT FX W/O MANI,2500254,CDM,450,RC,27500,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX FX GREAT TOE W/MANI,2500288,CDM,450,RC,28495,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX FX GREAT TOE W/O MANI,2500287,CDM,450,RC,28490,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX FX TOE (OTHER THAN GREAT) W/MAN,2500290,CDM,450,RC,28515,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX FX TOE (OTHER THAN GREAT) W/O M,2500289,CDM,450,RC,28510,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX FX WT BEARING PART DISTAL TIBIA,2500278,CDM,450,RC,27824,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX FX WT BEARING PART DISTAL TIBIA,2500279,CDM,450,RC,27825,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
"CLSED TX HIP DISLO TRAUMA, W/ANESTH",2500249,CDM,450,RC,27252,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
"CLSED TX HIP DISLO TRAUMA, W/O ANESTH",2500248,CDM,450,RC,27250,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX HUMERAL SHAFT FX W/MANI,2500216,CDM,450,RC,24505,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX HUMERAL SHAFT FX W/O MANI,2500215,CDM,450,RC,24500,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX INTERPHALANGEAL JNT DISLO W/ANE,2500292,CDM,450,RC,28665,HCPCS,outpatient,,,560.16,336.1,,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,274.32,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,120.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,215.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,504.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,352.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.02,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.78,1459.9,
CLSED TX KNEE DISLO W/ANEST,2500261,CDM,450,RC,27552,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX KNEE DISLO W/O ANEST,2500260,CDM,450,RC,27550,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX MEDIAL MALLEOLUS FX W/MANI,2500267,CDM,450,RC,27762,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX MEDIAL MALLEOLUS FX W/O MANI,2500266,CDM,450,RC,27760,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX METACARPAL FX SNGL W/MANI EA BO,2500238,CDM,450,RC,26605,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX METACARPAL FX SNGL W/O MANI EA,2500237,CDM,450,RC,26600,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX METACARPOPHAL DISLO SNGL W/MANI,2500229,CDM,450,RC,26700,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX METACARPOPHAL DISLO SNGL W/MANI,2500239,CDM,450,RC,26700,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX METACARPOPHAL DISLO SNGL W/MANI,2500240,CDM,450,RC,26705,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX METATARSAL FX W/MANI,2500286,CDM,450,RC,28475,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX METATARSAL FX W/O MANI,2500285,CDM,450,RC,28470,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX METATARSOPHALANGEAL JNT DISLO W,2500291,CDM,450,RC,28635,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX PATELLAR DISLO W/ANESTH,2500263,CDM,450,RC,27562,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX PATELLAR DISLO W/O ANESTH,2500262,CDM,450,RC,27560,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX PHAL SHAFT FX FNGR/THUMB W/MANI,2500242,CDM,450,RC,26725,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX PHAL SHAFT FX FNGR/THUMB W/O MA,2500241,CDM,450,RC,26720,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX POST MALLEOLUS FX W/MANI,2500269,CDM,450,RC,27768,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX POST MALLEOLUS FX W/O MANI,2500268,CDM,450,RC,27767,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX POST OP HIP ARTHRO DISLO W/ANES,2500253,CDM,450,RC,27266,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX POST OP HIP ARTHRO DISLO W/O AN,2500252,CDM,450,RC,27265,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX PROX FIBULA OR SHAFT FX W/MANI,2500271,CDM,450,RC,27781,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX PROX FIBULA OR SHAFT FX W/O MAN,2500270,CDM,450,RC,27780,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX PROX HUMERAL FX W/O MANI,2500209,CDM,450,RC,23600,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX PROX HUMERAL FX W/O MANI,2500210,CDM,450,RC,23600,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX RAD HD SUBLUX CHILD W/MANI,2500221,CDM,450,RC,24640,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX RAD HD/NECK FX W/MANI,2500223,CDM,450,RC,24655,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX RAD HD/NECK FX W/O MANI,2500222,CDM,450,RC,24650,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX RAD SHAFT FX W/MANI,2500227,CDM,450,RC,25505,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX RAD SHAFT FX W/O MANI,2500226,CDM,450,RC,25500,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX RAD/ULNAR SHAFT FXS W/MANI,2500231,CDM,450,RC,25565,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX RAD/ULNAR SHAFT FXS W/O MANI,2500230,CDM,450,RC,25560,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX SHOULDER DISLO W/MANI W/O ANEST,2500211,CDM,450,RC,23650,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX SHOULDER DISLO W/MANI/ANESTH,2500212,CDM,450,RC,23655,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX SUPER/TRANS FEMORAL FX W/MANI,2500257,CDM,450,RC,27503,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX SUPER/TRANS FEMORAL FX W/O MANI,2500255,CDM,450,RC,27501,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX TIBIAL SHAFT FX W/MANI,2500265,CDM,450,RC,27752,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX TIBIAL SHAFT FX W/O MANI,2500264,CDM,450,RC,27750,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX TRIMALLEOLAR ANKLE FX W/MANI,2500277,CDM,450,RC,27818,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX TRIMALLEOLAR ANKLE FX W/O MANI,2500276,CDM,450,RC,27816,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX ULNAR FX PROX END W/MANI,2500225,CDM,450,RC,24675,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
CLSED TX ULNAR FX PROX END W/O MANI,2500224,CDM,450,RC,24670,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
CLSED TX ULNAR SHAFT FX W/O MANI,2500228,CDM,450,RC,25530,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
COMPLEX PROCEDURE,2500008,CDM,450,RC,,,outpatient,,,3044.34,1826.6,,2283.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2435.47,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,648.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,648.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2053.58,100,,,case rate,100% Anthem case rate for outpatient setting,654.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2739.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2283.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2283.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2283.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2283.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,623.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1917.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,623.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,623.79,2739.91,
CONSCIOUS SEDATION,2500048,CDM,450,RC,99152,HCPCS,outpatient,,,181.67,109,,136.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,163.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,136.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,114.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.22,163.5,
CONT NASAL HEMORRHAGE ANT COMPLEX,2500312,CDM,450,RC,30903,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
CONT NASAL HEMORRHAGE ANT SIMPLE,2500311,CDM,450,RC,30901,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
CONT NASAL HEMORRHAGE POSTERIOR INITIAL,2500313,CDM,450,RC,30905,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
CPR,2500010,CDM,450,RC,92950,HCPCS,outpatient,,,701.53,420.92,,526.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,149.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,149.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,526.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,631.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,526.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,526.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,143.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,441.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,143.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,143.74,631.38,
CRITICAL CARE 30 TO 74 MINUTES,2500044,CDM,450,RC,99291,HCPCS,outpatient,,,2323.96,1394.38,,1742.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1859.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,675.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,877.84,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,495,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,495,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,248.92,100,,,case rate,100% Anthem case rate for outpatient setting,499.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,688.77,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2091.56,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1742.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1742.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1742.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1742.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,675.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,675.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,476.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2158,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,675.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,476.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,675.27,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,248.92,2158,
CRITICAL CARE EA ADDITIONAL 30 MIN,2500083,CDM,450,RC,99292,HCPCS,outpatient,,,1023.07,613.84,,767.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,818.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,217.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,767.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,219.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,920.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,767.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,644.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.63,920.76,
DEBRIDE BONE 1ST 20 SQ CM OR <,2500139,CDM,450,RC,11044,HCPCS,outpatient,,,3269.69,1961.81,,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2615.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1714.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1345.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2942.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2059.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,2942.72,
DEBRIDE BONE ADDNL 20 SQ CM OR PART,2500142,CDM,450,RC,11047,HCPCS,outpatient,,,1591.35,954.81,,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1273.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,338.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1432.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1002.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.07,1432.22,
DEBRIDE MUSCLE/FASCIA 1ST 20 SQ CM OR <,2500138,CDM,450,RC,11043,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
DEBRIDE MUSCLE/FASCIA ADDNL 20 SQ CM OR,2500141,CDM,450,RC,11046,HCPCS,outpatient,,,1591.35,954.81,,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1273.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,338.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,338.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,342.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1432.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1193.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1002.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,326.07,1432.22,
DEBRIDE NAILS 1-5 NAILS,2500143,CDM,450,RC,11720,HCPCS,outpatient,,,129.43,77.66,,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,27.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,1459.9,
DEBRIDE SUBQ TISSUE 1ST 20 SQ CM OR <,2500137,CDM,450,RC,11042,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
DEBRIDE SUBQ TISSUE EA ADDNL 20 SQ CM OR,2500140,CDM,450,RC,11045,HCPCS,outpatient,,,1060.9,636.54,,795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,848.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,225.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,228.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,954.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,795.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,668.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.38,954.81,
DRAIN SCROTAL WALL ABSCESS,2500350,CDM,450,RC,55100,HCPCS,outpatient,,,3269.69,1961.81,,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2615.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1714.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1345.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2942.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2059.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,2942.72,
DRESS/DEBRIDE PART THICK BRN LARGE,2500195,CDM,450,RC,16030,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
DRESS/DEBRIDE PART THICK BRN MED,2500194,CDM,450,RC,16025,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
DRESS/DEBRIDE PART THICK BRN SMALL,2500193,CDM,450,RC,16020,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
DX ANOSCOPY W/SPEC COLLECCTION,2500345,CDM,450,RC,46600,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
ED LVL 1 - W/PROCEDURE,2500127,CDM,450,RC,9928125,HCPCS,outpatient,,,168.68,101.21,,126.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,126.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,106.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.56,151.81,
ED LVL 2 - W/PROCEDURE,2500128,CDM,450,RC,9928225,HCPCS,outpatient,,,305.54,183.32,,229.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,274.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,192.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.61,274.99,
ED LVL 3 - W/PROCEDURE,2500129,CDM,450,RC,9928325,HCPCS,outpatient,,,537.88,322.73,,403.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,430.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,403.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,403.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,403.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,403.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,403.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,338.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,110.21,484.09,
ED LVL 4 - W/PROCEDURE,2500130,CDM,450,RC,9928425,HCPCS,outpatient,,,845.54,507.32,,634.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,676.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,634.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,760.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,634.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,634.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,532.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,173.25,760.99,
ED LVL 5 - W/PROCEDURE,2500131,CDM,450,RC,9928525,HCPCS,outpatient,,,1213.67,728.2,,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,970.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,258.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1092.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,910.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,764.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,248.68,1092.3,
EMERGENCY MEDICAL SCREENING,2500000,CDM,450,RC,99281,HCPCS,outpatient,,,80.32,48.19,,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65,100,,,case rate,100% ER case rate,65,100,,,case rate,100% ER case rate,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,100,,,case rate,100% ER case rate,67.36,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,72.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,235,100,,,case rate,100% ER case rate,50.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,100,,,case rate,100% ER case rate,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.6,235,
EMR INTUBATION,2500056,CDM,450,RC,31500,HCPCS,outpatient,,,491.2,294.72,,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,237.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,105.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,186.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,442.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,1459.9,
EMR TRACHEOSTOMY,2500314,CDM,450,RC,31605,HCPCS,outpatient,,,491.2,294.72,,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,237.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,105.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,186.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,442.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,1459.9,
EVAC SUBUNGUAL HEMATOMA,2500146,CDM,450,RC,11740,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
"Emergency department visit, problem with significant threat to life or function",2500005,CDM,450,RC,99285,HCPCS,outpatient,,,1196.43,717.86,,897.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,957.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,626.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,254.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,254.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2053.58,100,,,case rate,100% Anthem case rate for outpatient setting,162,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,491.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1076.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,897.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,897.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,897.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,897.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,235,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1620,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,2053.58,
"Emergency department visit, problem of high severity",2500004,CDM,450,RC,99284,HCPCS,outpatient,,,1071.51,642.91,,803.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,335.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,436.35,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,228.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,228.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.97,100,,,case rate,100% Anthem case rate for outpatient setting,162,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,342.36,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,964.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,803.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,803.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,335.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,235,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1620,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,335.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,335.65,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,1620,
EVALUATION AND MANAGEMENT LEVEL ONE,2500001,CDM,450,RC,99281,HCPCS,outpatient,,,484.56,290.74,,363.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,387.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65,100,,,case rate,100% ER case rate,65,100,,,case rate,100% ER case rate,363.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,100,,,case rate,100% ER case rate,67.36,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,436.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,363.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,235,100,,,case rate,100% ER case rate,305.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,100,,,case rate,100% ER case rate,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65,436.1,
"Emergency department visit, moderately severe problem",2500003,CDM,450,RC,99283,HCPCS,outpatient,,,726.72,436.03,,545.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,581.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,215.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,280.17,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,154.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,154.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.97,100,,,case rate,100% Anthem case rate for outpatient setting,162,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,219.83,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,654.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,545.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,215.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,215.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,235,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1620,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,215.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,215.52,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,154.79,1620,
EVALUATION AND MANAGEMENT LEVEL TWO,2500002,CDM,450,RC,99282,HCPCS,outpatient,,,588.27,352.96,,441.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,122.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,159.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,125.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,441.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,125.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,529.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,441.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,441.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,235,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,574,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,122.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,122.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.86,574,
EXC EXT THROMBOSED HEMORRHOID,2500344,CDM,450,RC,46320,HCPCS,outpatient,,,2409.3,1445.58,,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1927.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1238.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,513.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,513.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,518,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,971.55,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2168.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,493.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1517.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,493.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,493.67,2168.37,
FOLEY CATHETER INSERTION,2500078,CDM,450,RC,51702,HCPCS,outpatient,,,230.72,138.43,,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,184.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,49.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,49.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,207.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,145.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.27,1459.9,
FOLLOW UP VISIT,2500033,CDM,450,RC,99281,HCPCS,outpatient,,,155.17,93.1,,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.85,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65,100,,,case rate,100% ER case rate,65,100,,,case rate,100% ER case rate,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162,100,,,case rate,100% ER case rate,67.36,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,139.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,116.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,235,100,,,case rate,100% ER case rate,97.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,162,100,,,case rate,100% ER case rate,66.04,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65,235,
GASTRIC INTUBATION,2500088,CDM,450,RC,43753,HCPCS,outpatient,,,586.26,351.76,,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,126.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,527.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,369.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,1459.9,
GASTRIC INTUBATION THERAPEUTIC,2500340,CDM,450,RC,43753,HCPCS,outpatient,,,614.26,368.56,,460.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,491.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,130.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,132.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,552.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,460.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,460.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,125.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,386.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,125.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,125.86,1459.9,
GASTRIC LAVAGE,2500017,CDM,450,RC,43753,HCPCS,outpatient,,,586.26,351.76,,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,126.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,527.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,369.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,1459.9,
GASTROCULT,2582271,CDM,450,RC,82271,HCPCS,outpatient,,,13.79,8.27,,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.92,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,5.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,12.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.34,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.32,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4.87,12.41,
I&D ABSCESS FINGER,2500234,CDM,450,RC,26010,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
"I&D ABSCESS, COMPLEX",2500133,CDM,450,RC,10061,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
"I&D ABSCESS, PILONIDAL",2500134,CDM,450,RC,10080,HCPCS,outpatient,,,1437.52,862.51,,1078.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1150.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,742.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,306.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,306.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,309.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,582.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1293.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1078.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1078.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1078.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1078.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,294.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,905.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,294.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,294.55,1459.9,
Incision and drainage of abscess; simple or single and complex or multiple,2500132,CDM,450,RC,10060,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
I&D BARTHOLINS GLAND,2500351,CDM,450,RC,56420,HCPCS,outpatient,,,395.72,237.43,,296.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,316.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,203.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,84.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,85.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,159.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,356.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,296.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,296.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,249.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,81.08,1459.9,
I&D ISCHIO/PERIRECTAL ABSCESS,2500342,CDM,450,RC,46040,HCPCS,outpatient,,,2409.3,1445.58,,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1927.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1238.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,513.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,513.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,518,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,971.55,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2168.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1806.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,493.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1517.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,493.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,952.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,493.67,2168.37,
I&D PERIANAL ABSCESS SUPERFICIAL,2500343,CDM,450,RC,46050,HCPCS,outpatient,,,1748.36,1049.02,,1311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1398.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,950.25,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,372.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,372.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,375.9,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,745.58,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1573.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1311.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,358.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1101.47,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,358.24,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,730.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,358.24,1573.52,
I&D PERITONSILLER ABSCESS,2542700,CDM,450,RC,42700,HCPCS,outpatient,,,491.2,294.72,,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,237.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,105.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,186.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,442.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,1459.9,
I&D PERITONSILLER ABSCESS PRO FEE,2542701,CDM,450,RC,42700,HCPCS,outpatient,,,339.49,203.69,,254.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,237.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,72.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,72.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,186.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,305.54,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,254.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,213.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.56,1459.9,
INERT CENTRAL LINE <5YO,2500327,CDM,450,RC,36555,HCPCS,outpatient,,,6649.72,3989.83,,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5319.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3406.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1416.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1416.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1429.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2672.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5984.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1362.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4189.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1362.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1362.53,5984.75,
INERT CENTRAL LINE => 5YO,2500328,CDM,450,RC,36556,HCPCS,outpatient,,,6649.72,3989.83,,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5319.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3406.31,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1416.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1416.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1429.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2672.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5984.75,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4987.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1362.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4189.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1362.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2620.23,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1362.53,5984.75,
INJ ANESTH/STEROID OCCIPITAL NERVE,2500356,CDM,450,RC,64405,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
INJ ANESTH/STEROID OTHER PERIPHERAL NERV,2500357,CDM,450,RC,64450,HCPCS,outpatient,,,1474.65,884.79,,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1179.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,314.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,317.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1327.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,929.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,1459.9,
INJ ANESTH/STEROID TRIGEMINAL NERVE EA B,2500355,CDM,450,RC,64400,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
INJ DX/TX AGNT PARAVERTEBRAL FACET JNT C,2500358,CDM,450,RC,64490,HCPCS,outpatient,,,1910.68,1146.41,,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1528.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,406.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,406.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,410.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1719.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,391.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1203.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,391.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,391.5,1719.61,
Injection into lower back of nerve block using imaging guidance,2500359,CDM,450,RC,64493,HCPCS,outpatient,,,1910.68,1146.41,,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1528.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,974.42,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,406.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,406.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,410.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,764.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1719.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1433.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,391.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1203.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,391.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,749.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,391.5,1719.61,
INJ SACROILIAC JOINT W/GUIDE,2500247,CDM,450,RC,27096,HCPCS,outpatient,,,216.42,129.85,,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,173.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,46.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,162.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,136.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.34,1459.9,
Injection of medication into the tendon/ligament origin,2500196,CDM,450,RC,20551,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
INJ SINGLE/MULT TRIGGER PTS 1-2 MUSCLES,2500197,CDM,450,RC,20552,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
Injection of medication into an area that triggers pain,2500198,CDM,450,RC,20553,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,310.88,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,243.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,239.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
"INS&REM FB, SUBQ TISSUES, COMPLEX",2500136,CDM,450,RC,10121,HCPCS,outpatient,,,3269.69,1961.81,,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2615.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1714.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1345.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2942.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2059.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,2942.72,
"INS&REM FB, SUBQ TISSUES, SIMPLE",2500135,CDM,450,RC,10120,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
INSERT IV HEPLOCK,2500080,CDM,450,RC,36000,HCPCS,outpatient,,,42.23,25.34,,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.65,38.01,
INSERT STRAIGHT CATH NON INDWELLING,2500113,CDM,450,RC,51701,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
INSERT TEMP INDWELLING CATH COMPLICATED,2500114,CDM,450,RC,51703,HCPCS,outpatient,,,324.64,194.78,,243.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,259.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,69.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,292.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,243.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,204.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.52,1459.9,
INT TX 1ST DEGREE BURN (LOCAL TX),2500192,CDM,450,RC,16000,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
INTERMEDIATE PROCEDURE,2500007,CDM,450,RC,,,outpatient,,,941.11,564.67,,705.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,752.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,200.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2053.58,100,,,case rate,100% Anthem case rate for outpatient setting,202.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,847,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,705.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,705.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,592.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,192.83,2053.58,
MINOR PROCEDURES IN ER 16-29 MIN,2500045,CDM,450,RC,,,outpatient,,,604.61,362.77,,453.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,483.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,128.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2053.58,100,,,case rate,100% Anthem case rate for outpatient setting,129.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,544.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,453.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,453.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,453.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,453.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,380.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.88,2053.58,
"MOD SED OTHER PHYS <5YO, 15 MIN",2500377,CDM,450,RC,99155,HCPCS,outpatient,,,150.65,90.39,,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,135.59,
"MOD SED OTHER PHYS =>5YO, 15 MIN",2500378,CDM,450,RC,99156,HCPCS,outpatient,,,150.65,90.39,,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.59,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,135.59,
MOD SED OTHER PHYS EA ADDNL 15 MIN,2500379,CDM,450,RC,99157,HCPCS,outpatient,,,93.36,56.02,,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,74.69,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.02,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.13,84.02,
"MOD SED SAME PHYS <5YO, 15 MIN",2500374,CDM,450,RC,99151,HCPCS,outpatient,,,176.11,105.67,,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,110.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,158.5,
"MOD SED SAME PHYS =>5YO, 15 MIN",2500375,CDM,450,RC,99152,HCPCS,outpatient,,,176.11,105.67,,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,110.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,158.5,
MOD SED SAME PHYS EA ADDNL 15 MIN,2500376,CDM,450,RC,99153,HCPCS,outpatient,,,176.11,105.67,,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,110.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.08,158.5,
NASO/ORO GASTRIC TUBE PLACEMENT W/GUIDE,2500339,CDM,450,RC,43752,HCPCS,outpatient,,,628.05,376.83,,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,135.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,565.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,1459.9,
NURSING PROCEDURE,2500087,CDM,450,RC,,,outpatient,,,85.49,51.29,,64.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2053.58,100,,,case rate,100% Anthem case rate for outpatient setting,18.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,53.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,2053.58,
Pacemaker Interrogation,2593288,CDM,450,RC,93288,HCPCS,outpatient,,,85.93,51.56,,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,30.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,18.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,31.4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,77.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,30.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,54.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,30.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,30.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.61,77.34,
PERC TRANSCATH SEPTAL TX W/PACEMAKER INS,2500372,CDM,450,RC,93583,HCPCS,outpatient,,,1921.29,1152.77,,1440.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1537.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1921.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1921.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,409.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,409.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4903.69,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,413.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1921.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1729.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1440.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1440.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1921.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1921.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,393.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1210.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1921.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,393.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1921.29,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,393.67,4903.69,
PERICARDIOCENTESIS,2500320,CDM,450,RC,33016,HCPCS,outpatient,,,3267.57,1960.54,,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2614.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1701.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,695.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,695.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1334.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2940.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2058.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,2940.81,
PERICARDIOTOMY REM CLOT/FB,2500321,CDM,450,RC,33020,HCPCS,outpatient,,,3267.57,1960.54,,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2614.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3267.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3267.57,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,695.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,695.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3891.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,3267.57,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2940.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3267.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3267.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2058.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,3267.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3267.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,3891.84,
PERITONEAL LAVAGE,2500348,CDM,450,RC,49084,HCPCS,outpatient,,,1880.98,1128.59,,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,943.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,404.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,740.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1692.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1185.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,1692.88,
Vaginal delivery of placenta,2500353,CDM,450,RC,59414,HCPCS,outpatient,,,6094.87,3656.92,,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4875.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3233.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1298.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1298.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1310.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2536.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5485.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1248.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3839.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1248.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1248.84,5485.38,
PLACMT NEEDLE FOR INTRAOSSEOUS INF,2500330,CDM,450,RC,36680,HCPCS,outpatient,,,628.05,376.83,,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,135.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,565.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,1459.9,
Ultrasound of bladder to measure urine capacity,2500349,CDM,450,RC,51798,HCPCS,outpatient,,,129.43,77.66,,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,116.49,
REM CORNEAL EPITHELIUM W/WO CHEMO,2500364,CDM,450,RC,65435,HCPCS,outpatient,,,1880.98,1128.59,,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,767.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,997.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,404.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,782.9,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1692.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,767.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,767.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1185.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,767.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,1946.54,
REM EMBEDDED FB EYELID,2500365,CDM,450,RC,67938,HCPCS,outpatient,,,606.83,364.1,,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,485.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,232.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.68,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,130.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,237.48,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,546.15,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,455.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,382.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,232.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,232.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,124.34,1459.9,
REM EMBEDDED FB MOUTH VESTIBULE COMPLEX,2500334,CDM,450,RC,40805,HCPCS,outpatient,,,1051.35,630.81,,788.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,841.08,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,401.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,522.34,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,223.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,226.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,409.84,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,946.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,788.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,401.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,401.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,215.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,662.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,401.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,215.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,401.81,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,215.42,1459.9,
REM EMBEDDED FB MOUTH VESTIBULE SIMPLE,2500333,CDM,450,RC,40804,HCPCS,outpatient,,,1880.98,1128.59,,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,943.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,404.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,740.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1692.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1185.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,1692.88,
REM FB EXT EYE CONJUNCTIVAL EMBEDDED/SUB,2500361,CDM,450,RC,65210,HCPCS,outpatient,,,628.05,376.83,,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,135.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,565.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,1459.9,
REM FB EXT EYE CONJUNCTIVAL SUPERFICIAL,2500360,CDM,450,RC,65205,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
REM FB EXT EYE CORNEAL W/ SLIT LAMP,2500363,CDM,450,RC,65222,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
REM FB EXT EYE CORNEAL W/O SLIT LAMP,2500362,CDM,450,RC,65220,HCPCS,outpatient,,,628.05,376.83,,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,135.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,565.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,1459.9,
REM FB EXTERNAL EAR W/O ANESTH,2500366,CDM,450,RC,69200,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
REM FB FOOT COMPLICATED,2500284,CDM,450,RC,28193,HCPCS,outpatient,,,3269.69,1961.81,,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2615.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1714.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1345.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2942.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2059.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,2942.72,
REM FB FOOT DEEP,2500283,CDM,450,RC,28192,HCPCS,outpatient,,,3269.69,1961.81,,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2615.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1714.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1345.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2942.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2059.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,2942.72,
REM FB FOOT SUBQ,2500282,CDM,450,RC,28190,HCPCS,outpatient,,,1444.95,866.97,,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,742.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,307.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,307.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,310.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,582.22,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1300.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,296.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,910.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,296.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,570.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,296.07,1459.9,
REM FB INTRANASAL,2500310,CDM,450,RC,30300,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
REM FB PELVIS/HIP DEEP,2500246,CDM,450,RC,27087,HCPCS,outpatient,,,6576.52,3945.91,,4932.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5261.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2618.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3403.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1400.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1400.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2270.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1413.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2670.57,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5918.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4932.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4932.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4932.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4932.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2618.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2618.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1347.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4143.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2618.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1347.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2618.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1347.53,5918.87,
REM FB PELVIS/HIP SUBQ,2500245,CDM,450,RC,27086,HCPCS,outpatient,,,5507.13,3304.28,,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4405.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2953.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1173.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1173.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1184.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2317.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,4956.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3469.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,4956.42,
REM FB PHARYNX,2500338,CDM,450,RC,42809,HCPCS,outpatient,,,626.99,376.19,,470.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,134.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,564.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,470.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,470.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.47,1459.9,
REM FB SHOULDER DEEP (SUBFASC/IM),2500206,CDM,450,RC,23333,HCPCS,outpatient,,,5507.13,3304.28,,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4405.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2953.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1173.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1173.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1184.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2317.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,4956.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3469.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,4956.42,
REM FB SHOULDER SUBQ,2500205,CDM,450,RC,23330,HCPCS,outpatient,,,1444.95,866.97,,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1155.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1714.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,307.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,307.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,310.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1345.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1300.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1083.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,296.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,910.32,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,296.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,296.07,1714.66,
REM FB UPPER ARM/ELBOW DEEP,2500214,CDM,450,RC,24201,HCPCS,outpatient,,,5507.13,3304.28,,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4405.7,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2953.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1173.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1173.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2270.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1184.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2317.61,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,4956.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4130.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3469.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2272.17,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1128.41,4956.42,
REM FB UPPER ARM/ELBOW SUBQ,2500213,CDM,450,RC,24200,HCPCS,outpatient,,,3269.69,1961.81,,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2615.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1714.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,696.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1345.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2942.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2452.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2059.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.96,2942.72,
REM IMPACTED CREUMEN IRRG/LAV UNILAT,2500367,CDM,450,RC,69209,HCPCS,outpatient,,,129.43,77.66,,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,27.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,1459.9,
Removal of ear wax from one or both ears,2500368,CDM,450,RC,69210,HCPCS,outpatient,,,129.43,77.66,,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,27.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,1459.9,
REP CARDIAC WND W/O BYPASS,2500322,CDM,450,RC,33300,HCPCS,outpatient,,,6337.82,3802.69,,4753.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5070.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,6337.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6337.82,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1349.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1349.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4865.11,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1362.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6337.82,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5704.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4753.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4753.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4753.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4753.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6337.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6337.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1298.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3992.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,6337.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1298.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6337.82,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1298.62,6337.82,
REP COMPLEX ENEL 1.1-2.5CM,2500189,CDM,450,RC,13151,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP COMPLEX ENEL 2.6-7.5CM,2500190,CDM,450,RC,13152,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP COMPLEX ENEL EA ADDNL 5CM OR<,2500191,CDM,450,RC,13153,HCPCS,outpatient,,,332.06,199.24,,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,298.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,209.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,298.85,
REP COMPLEX FCCMNAGHF 1.1-2.5CM,2500186,CDM,450,RC,13131,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP COMPLEX FCCMNAGHF 2.6-7.5CM,2500187,CDM,450,RC,13132,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP COMPLEX FCCMNAGHF EA ADDNL 5CM OR<,2500188,CDM,450,RC,13133,HCPCS,outpatient,,,332.06,199.24,,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,298.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,209.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,298.85,
REP COMPLEX SAL 1.1-2.5CM,2500183,CDM,450,RC,13120,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP COMPLEX SAL 2.6-7.5CM,2500184,CDM,450,RC,13121,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP COMPLEX SAL EA ADDNL 5CM OR<,2500185,CDM,450,RC,13122,HCPCS,outpatient,,,332.06,199.24,,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,298.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,209.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,298.85,
REP COMPLEX TRUNK 1.1-2.5CM,2500180,CDM,450,RC,13100,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP COMPLEX TRUNK 2.6-7.5CM,2500181,CDM,450,RC,13101,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP COMPLEX TRUNK EA ADDNL 5CM OR<,2500182,CDM,450,RC,13102,HCPCS,outpatient,,,332.06,199.24,,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,265.65,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,298.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,209.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.04,298.85,
REP EXT TENDON FINGER WO GRAFT EA TENDON,2500236,CDM,450,RC,26418,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
REP EXT TENDON HAND EA TENDON,2500235,CDM,450,RC,26410,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
REP INT WND FEENLMM >30.0CM,2500179,CDM,450,RC,12057,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND FEENLMM 12.6-20.0CM,2500177,CDM,450,RC,12055,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND FEENLMM 2.5CM or <,2500173,CDM,450,RC,12051,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND FEENLMM 2.6-5.0CM,2500174,CDM,450,RC,12052,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND FEENLMM 20.1-30.0CM,2500178,CDM,450,RC,12056,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND FEENLMM 5.1-7.5CM,2500175,CDM,450,RC,12053,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND FEENLMM 7.6-12.5CM,2500176,CDM,450,RC,12054,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND NHF OR EXTGEN >30.0CM,2500172,CDM,450,RC,12047,HCPCS,outpatient,,,3985.8,2391.48,,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1973.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,848.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,848.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,856.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1548.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3587.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,816.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2511.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,816.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,816.69,3587.22,
REP INT WND NHF OR EXTGEN 12.6-20.0CM,2500170,CDM,450,RC,12045,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP INT WND NHF OR EXTGEN 2.5CM OR<,2500167,CDM,450,RC,12041,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND NHF OR EXTGEN 2.6-7.5CM,2500168,CDM,450,RC,12042,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND NHF OR EXTGEN 20.1-30.0CM,2500171,CDM,450,RC,12046,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP INT WND NHF OR EXTGEN 7.6-12.5CM,2500169,CDM,450,RC,12044,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP INT WND SAT OR EXT >30.0CM,2500166,CDM,450,RC,12037,HCPCS,outpatient,,,3985.8,2391.48,,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3188.64,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1973.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,848.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,848.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,856.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1548.38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3587.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2989.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,816.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2511.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,816.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1518.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,816.69,3587.22,
REP INT WND SAT OR EXT 12.6-20.0CM,2500164,CDM,450,RC,12035,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND SAT OR EXT 2.5CM OR<,2500161,CDM,450,RC,12031,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND SAT OR EXT 2.6-7.5CM,2500162,CDM,450,RC,12032,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP INT WND SAT OR EXT 20.1-30.0CM,2500165,CDM,450,RC,12036,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REP INT WND SAT OR EXT 7.6-12.5CM,2500163,CDM,450,RC,12034,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP LACERATION POST 1/3 TONGUE,2500336,CDM,450,RC,41251,HCPCS,outpatient,,,491.2,294.72,,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,237.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,105.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,186.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,442.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,1459.9,
"REP LACERATION TONGUE, MOUTH FLOOR, 2.6C",2500337,CDM,450,RC,41252,HCPCS,outpatient,,,491.2,294.72,,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,392.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,237.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.63,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,105.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,186.45,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,442.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,368.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,309.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.8,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,100.65,1459.9,
REP SIMPL SUPER WND FEENLMM >30.0 CM,2500160,CDM,450,RC,12018,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP SIMPL SUPER WND FEENLMM 12.6-20.0 CM,2500158,CDM,450,RC,12016,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",2500154,CDM,450,RC,12011,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP SIMPL SUPER WND FEENLMM 2.6-5.0 CM,2500155,CDM,450,RC,12013,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP SIMPL SUPER WND FEENLMM 20.1-30.0 CM,2500159,CDM,450,RC,12017,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP SIMPL SUPER WND FEENLMM 5.1-7.5 CM,2500156,CDM,450,RC,12014,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP SIMPL SUPER WND FEENLMM 7.6-12.5 CM,2500157,CDM,450,RC,12015,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP SIMPL SUPER WND SNAGT >30.0 CM,2500153,CDM,450,RC,12007,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP SIMPL SUPER WND SNAGT 12.6-20.0 CM,2500151,CDM,450,RC,12005,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",2500148,CDM,450,RC,12001,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP SIMPL SUPER WND SNAGT 2.6-7.5 CM,2500149,CDM,450,RC,12002,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP SIMPL SUPER WND SNAGT 20.1-30.0 CM,2500152,CDM,450,RC,12006,HCPCS,outpatient,,,803.1,481.86,,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,426.58,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,334.7,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,722.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,505.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,328.14,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.56,1459.9,
REP SIMPL SUPER WND SNAGT 7.6-12.5 CM,2500150,CDM,450,RC,12004,HCPCS,outpatient,,,416.93,250.16,,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,333.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,162.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,375.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,312.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,262.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.43,1459.9,
REP WND LACERATION MOUTH 2.5CM OR <,2500335,CDM,450,RC,41250,HCPCS,outpatient,,,628.05,376.83,,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,135.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,565.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,1459.9,
REPAIR NAIL BED,2500147,CDM,450,RC,11760,HCPCS,outpatient,,,1217.91,730.75,,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,974.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,259.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,261.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1096.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,913.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,767.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,249.55,1459.9,
REPLACE GASTROSTOMY TUBE W/O IMAGING,2500341,CDM,450,RC,43762,HCPCS,outpatient,,,618.5,371.1,,463.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,494.8,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,188.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,245.69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,131.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,131.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,132.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,192.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,556.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,463.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,463.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,188.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,126.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,389.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,188.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,126.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,188.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,126.73,1459.9,
SPINAL PUNCTURE DX,2500354,CDM,450,RC,62270,HCPCS,outpatient,,,1474.65,884.79,,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1179.72,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,314.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,317.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1327.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1105.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,929.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,302.16,1459.9,
STRAPPING ANKLE/FOOT,2500307,CDM,450,RC,29540,HCPCS,outpatient,,,327.82,196.69,,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,70.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,295.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,206.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,1459.9,
STRAPPING ELBOW OR WRIST,2500300,CDM,450,RC,29260,HCPCS,outpatient,,,129.43,77.66,,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,27.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,1459.9,
STRAPPING HAND OR FINGER,2500301,CDM,450,RC,29280,HCPCS,outpatient,,,129.43,77.66,,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,27.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,1459.9,
STRAPPING KNEE,2500306,CDM,450,RC,29530,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
STRAPPING SHOULDER,2500299,CDM,450,RC,29240,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
STRAPPING THORAX,2500298,CDM,450,RC,29200,HCPCS,outpatient,,,327.82,196.69,,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,70.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,295.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,206.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,1459.9,
STRAPPING TOES,2500308,CDM,450,RC,29550,HCPCS,outpatient,,,129.43,77.66,,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,27.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,81.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,1459.9,
STRAPPING UNNA BOOT,2500309,CDM,450,RC,29580,HCPCS,outpatient,,,327.82,196.69,,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,262.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,70.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.76,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,295.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,206.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,67.17,1459.9,
TEMP TRANSCUTANEUS PACING,2500369,CDM,450,RC,92953,HCPCS,outpatient,,,1305.97,783.58,,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1044.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,672.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,278.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,278.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,527.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1175.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,979.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,822.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.59,1175.37,
THORACENTESIS,2500061,CDM,450,RC,32554,HCPCS,outpatient,,,1725.41,1035.25,,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1380.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,661.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,367.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,367.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,370.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,519.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1552.87,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1294.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1087.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,353.54,1552.87,
THORACENTESIS TUBE W/O GUIDE,2500370,CDM,450,RC,32554,HCPCS,outpatient,,,1258.23,754.94,,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1006.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,661.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,268,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,268,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,270.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,519.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1132.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,792.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.81,1459.9,
THORACENTESIS W/GUIDANCE,2500319,CDM,450,RC,32555,HCPCS,outpatient,,,1258.23,754.94,,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1006.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,661.48,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,268,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,268,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,270.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,519.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1132.41,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,943.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,792.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,508.83,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,257.81,1459.9,
THORACOTOMY CONT TRAUMATIC HEM,2500316,CDM,450,RC,32110,HCPCS,outpatient,,,3712.09,2227.25,,2784.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2969.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,3712.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3712.09,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,790.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,790.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3891.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,798.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,3712.09,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3340.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2784.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2784.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3712.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3712.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,760.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2338.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,3712.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,760.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3712.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,760.61,3891.84,
THORACOTOMY W/CARDIAC MASSAGE,2500317,CDM,450,RC,32160,HCPCS,outpatient,,,8627.24,5176.34,,6470.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6901.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8627.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8627.24,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1837.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1837.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3891.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1854.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8627.24,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,7764.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6470.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6470.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6470.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6470.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8627.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8627.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1767.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5435.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,8627.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1767.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8627.24,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1767.72,8627.24,
THORACOTOMY W/EXP,2500315,CDM,450,RC,32100,HCPCS,outpatient,,,10383.03,6229.82,,7787.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8306.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,10383.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10383.03,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,2211.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2211.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3891.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2232.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,10383.03,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,9344.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7787.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7787.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7787.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7787.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10383.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10383.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2127.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6541.31,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,10383.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2127.48,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10383.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2127.48,10383.03,
THROMBOLYSIS CEREBRAL BY IV INFUSION,2500112,CDM,450,RC,37195,HCPCS,outpatient,,,722.47,433.48,,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,577.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,380.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,153.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,155.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,298.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,650.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,455.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,1459.9,
THROMBOLYSIS CEREBRAL INFUSION,2500331,CDM,450,RC,37195,HCPCS,outpatient,,,722.47,433.48,,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,577.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,380.33,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,153.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,153.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,155.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,298.41,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,650.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,541.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,455.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,148.03,1459.9,
TRANSFUSION BLOOD OR COMPONENTS,2500104,CDM,450,RC,36430,HCPCS,outpatient,,,922.98,553.79,,692.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,466.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,196.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,198.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,365.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,830.68,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,692.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,692.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,189.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,581.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,189.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,358.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,189.12,1459.9,
TUBE THORACOSTOMY OPEN,2500318,CDM,450,RC,32551,HCPCS,outpatient,,,3267.57,1960.54,,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2614.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1701.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,695.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,695.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,702.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1334.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2940.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2450.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2058.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,669.53,2940.81,
TX CLSED ELBOW DISLO W/ANESTH,2500220,CDM,450,RC,24605,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
TX CLSED ELBOW DISLO W/O ANESTH,2500219,CDM,450,RC,24600,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,182.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1459.9,
TX SPONTANEOUS HIP DISLO W/MANI/ANESTH,2500251,CDM,450,RC,27257,HCPCS,outpatient,,,3235.75,1941.45,,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,695.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.18,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2038.52,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.01,2912.18,
TX SPONTANEOUS HIP DISLO W/O MANI/ANESTH,2500250,CDM,450,RC,27257,HCPCS,outpatient,,,479.53,287.72,,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,383.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1640.3,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,103.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1287.01,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,431.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,302.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1261.77,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,98.26,1946.54,
VACCINE/TOX ADMIN EA ADD,2500090,CDM,450,RC,90472,HCPCS,outpatient,,,103.81,62.29,,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.27,93.43,
Immunization administration in children <18,2500098,CDM,450,RC,90460,HCPCS,outpatient,,,92.34,55.4,,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.92,83.11,
VACCINE/TOXOIDS ADMIN EA ADDNL,2500076,CDM,450,RC,90472,HCPCS,outpatient,,,103.81,62.29,,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.27,93.43,
Vaginal delivery,2500352,CDM,450,RC,59409,HCPCS,outpatient,,,6094.87,3656.92,,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4875.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3233.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1298.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1298.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1310.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2536.69,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,5485.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4571.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1248.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3839.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1248.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2486.96,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1248.84,5485.38,
VASCULAR EMBOLIZATION OR OCCLUSION,2500332,CDM,450,RC,37244,HCPCS,outpatient,,,23336.62,14001.97,,17502.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18669.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,9337.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12138.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4970.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4970.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4865.11,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5017.37,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,9523.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,21002.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,17502.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17502.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17502.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17502.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9337.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9337.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4781.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14702.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,9337.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4781.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,9337.01,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4781.67,21002.96,
Collection of venous blood by venipuncture,2536415,CDM,450,RC,36415,HCPCS,outpatient,,,8.49,5.09,,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,8.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,7.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.74,11.14,
VENIPUNCTURE <3YO,2500323,CDM,450,RC,36400,HCPCS,outpatient,,,32.89,19.73,,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,29.6,
VENIPUNCTURE >3YO,2500324,CDM,450,RC,36410,HCPCS,outpatient,,,32.89,19.73,,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,20.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.74,29.6,
VENIPUNCTURE CUTDOWN <1YO,2500325,CDM,450,RC,36420,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,1459.9,
VENIPUNCTURE CUTDOWN >1YO,250032,CDM,450,RC,36425,HCPCS,outpatient,,,628.05,376.83,,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,135.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,565.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,1459.9,
VENIPUNCTURE CUTDOWN >1YO,2500326,CDM,450,RC,36425,HCPCS,outpatient,,,628.05,376.83,,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,502.44,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,431.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,133.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,135.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,338.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,565.25,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,471.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,395.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,332.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.69,1459.9,
"VENIPUNCTURE, CAP",2536416,CDM,450,RC,36416,HCPCS,outpatient,,,3.18,1.91,,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,2.86,
"VENIPUNCTURE, CL/CVD",2536592,CDM,450,RC,36592,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,233.93,
"VENIPUNCTURE, IMP DEVICE",2536591,CDM,450,RC,36591,HCPCS,outpatient,,,259.92,155.95,,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,233.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,163.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.26,233.93,
AIRWAY RESISTANCE BY OSCILLOMETRY,5294728,CDM,460,RC,94728,HCPCS,outpatient,,,561.22,336.73,,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,505.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,505.1,
Test to determine if wheezing is present,5294060,CDM,460,RC,94060,HCPCS,outpatient,,,561.22,336.73,,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,505.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,505.1,
"CARDIOPULM EXERCISE W/CO2 PROD, O2 UT, E",5294621,CDM,460,RC,94621,HCPCS,outpatient,,,561.22,336.73,,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,505.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,505.1,
Test to measure how well gases diffuse across lung surfaces,5294729,CDM,460,RC,94729,HCPCS,outpatient,,,44.35,26.61,,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.09,341,
ETCO2 MONITOR,2600075,CDM,460,RC,94770,HCPCS,outpatient,,,586.26,351.76,,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.12,527.63,
"EXE BRONCHOSPASM W/PRE POST SPIRO, W/O E",5294619,CDM,460,RC,94619,HCPCS,outpatient,,,118.08,70.85,,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.19,341,
"EXE BRONCHOSPASM W/PRE/POST SPIRO, W/EC",5294617,CDM,460,RC,94617,HCPCS,outpatient,,,237.64,142.58,,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,50.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,213.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,341,
Measure of lung function and gas exchange,5294727,CDM,460,RC,94727,HCPCS,outpatient,,,295.99,177.59,,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,63.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,266.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,341,
MAX BREATHING CAP/VOLUN VENTILATION,5294200,CDM,460,RC,94200,HCPCS,outpatient,,,117.76,70.66,,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,25.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,105.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,24.13,341,
Test to determine how well oxygen moves from the lungs to the blood stream,2600079,CDM,460,RC,94010,HCPCS,outpatient,,,319.9,191.94,,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,287.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,341,
Test to determine how well oxygen moves from the lungs to the blood stream,2600026,CDM,460,RC,94010,HCPCS,outpatient,,,319.9,191.94,,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,287.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,341,
Test to determine if wheezing is present,2600027,CDM,460,RC,94060,HCPCS,outpatient,,,586.26,351.76,,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,527.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,527.63,
Measures how much air is in the lungs after taking a deep breath,5294726,CDM,460,RC,94726,HCPCS,outpatient,,,561.22,336.73,,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,505.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,505.1,
PULMONARY STRESS TEST (6-MINUTE WALK),5294618,CDM,460,RC,94618,HCPCS,outpatient,,,237.64,142.58,,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,190.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,50.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,213.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,178.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.69,341,
PULSE OXIMETRY CHECK,2600065,CDM,460,RC,94760,HCPCS,outpatient,,,96.44,57.86,,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.76,341,
PULSE OXIMETRY CONT MONITORING,2600066,CDM,460,RC,94762,HCPCS,outpatient,,,319.9,191.94,,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,287.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,341,
PULSE OXIMETRY FOR O2 SATURATION,5294762,CDM,460,RC,94762,HCPCS,outpatient,,,295.99,177.59,,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,63.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,266.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,341,
PULSE OXIMETRY MULT CHECKS DAILY,2600068,CDM,460,RC,94761,HCPCS,outpatient,,,104.36,62.62,,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.92,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.38,341,
Graphical representation of inspiration and expiration,5294375,CDM,460,RC,94375,HCPCS,outpatient,,,561.22,336.73,,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,505.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,420.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,114.99,505.1,
Test to determine how well oxygen moves from the lungs to the blood stream,5294010,CDM,460,RC,94010,HCPCS,outpatient,,,295.99,177.59,,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,63.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,266.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,341,
UNLISTED PULMONARY SERVICE/PROCEDURE,5294799,CDM,460,RC,94799,HCPCS,outpatient,,,295.99,177.59,,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.79,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,63.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,266.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,221.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.65,341,
"VITAL CAPACITY, TOTAL",5294150,CDM,460,RC,94150,HCPCS,outpatient,,,265.23,159.14,,198.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,56.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,56.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,198.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.47,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,238.71,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,198.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.35,341,
HEARING SCREENING FOR NEWBORNS,1750006,CDM,479,RC,92587,HCPCS,outpatient,,,586.26,351.76,,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,527.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,238,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,527.63,
CARDIOVERSION,1000023,CDM,480,RC,92960,HCPCS,outpatient,,,1509.33,905.6,,1132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1207.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,672.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,321.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,321.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,527.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1358.4,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1132,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,309.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,309.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,309.26,1358.4,
CARDIOVERSION,2500054,CDM,480,RC,92960,HCPCS,outpatient,,,1191.07,714.64,,893.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,672.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,253.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,253.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,893.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,527.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1071.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,893.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,893.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,244.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,244.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,244.05,1071.96,
EXTERNAL PACEMAKER,2500055,CDM,480,RC,92953,HCPCS,outpatient,,,1213.21,727.93,,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,970.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,672.51,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,258.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,258.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,260.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,527.66,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1091.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,909.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,248.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,248.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,517.3,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,248.59,1091.89,
Test to screen the heart for abnormalities,1600154,CDM,480,RC,93303,HCPCS,outpatient,,,1134.52,680.71,,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,907.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,575.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,451.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1021.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,1021.07,
US F/U ECHO CONGENITAL ANOMALIES,1600155,CDM,480,RC,93304,HCPCS,outpatient,,,1134.52,680.71,,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,907.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,575.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,241.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,243.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,451.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1021.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,850.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,232.46,1021.07,
CPR,2600038,CDM,482,RC,92950,HCPCS,outpatient,,,340.93,204.56,,255.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,272.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,72.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,255.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,306.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,255.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,563,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.86,563,
NM STRESS EKG TRACING,1600108,CDM,482,RC,93017,HCPCS,outpatient,,,603.73,362.24,,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,128.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,543.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,563,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.7,563,
TREADMILL,1800002,CDM,482,RC,93017,HCPCS,outpatient,,,311.43,186.86,,233.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.14,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,66.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,233.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,280.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,233.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,233.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,563,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.81,563,
"US F/U DOP ECHO PW, CW W SPECTRAL DISP",1600162,CDM,482,RC,93321,HCPCS,outpatient,,,622.85,373.71,,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,563,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,563,
WALKING TREADMILL EKG TEST,1620088,CDM,482,RC,93017,HCPCS,outpatient,,,603.73,362.24,,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.23,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,128.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,128.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,129.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,543.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,563,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,123.7,563,
US DOP ECHO COLOR FLOW VELOCITY,1600160,CDM,483,RC,93325,HCPCS,outpatient,,,622.85,373.71,,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,560.57,
Echo with doppler,1600158,CDM,483,RC,93320,HCPCS,outpatient,,,622.85,373.71,,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,498.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,560.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,467.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.62,560.57,
"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",1600153,CDM,483,RC,93306,HCPCS,outpatient,,,761.17,456.7,,570.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,608.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,575.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,162.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,162.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,570.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,163.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,451.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,685.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,570.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,570.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,155.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,155.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,442.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,155.96,685.05,
US ECHO LIMITED F/U,1600661,CDM,483,RC,93308,HCPCS,outpatient,,,611.92,367.15,,458.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,489.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,130.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,130.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,458.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,550.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,458.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,458.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,125.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,341,100,,,case rate,100% UHC case rate for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,125.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,125.38,550.73,
BLOOD COLL FROM IMPLANTABLE DEVISE,1000028,CDM,510,RC,36591,HCPCS,outpatient,,,251.88,151.13,,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,226.69,
CHALLENGE STRESS TEST,1750003,CDM,510,RC,59020,HCPCS,outpatient,,,383.27,229.96,,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,203.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,81.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,159.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,344.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,241.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.53,344.94,
Outpatient visit of established patient not requiring a physician,1000001,CDM,510,RC,99211,HCPCS,outpatient,,,141.23,84.74,,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,88.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.94,127.11,
COMPREHENSIVE MGMT SKILL 1 NEW PATIENT,2750000,CDM,510,RC,,,outpatient,,,465.63,279.38,,349.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,99.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,349.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,419.07,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,349.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,349.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,293.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,95.41,419.07,
DEBRIDEMENT FULL THICKNESS,2810009,CDM,510,RC,,,outpatient,,,410.05,246.03,,307.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,87.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,87.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,307.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,369.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,307.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,258.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.02,369.05,
DEBRIDEMENT PARTIAL THICKNESS,2810008,CDM,510,RC,,,outpatient,,,248.6,149.16,,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,223.74,
DEBRIDEMENT SKIN & SUBQ,2810010,CDM,510,RC,,,outpatient,,,683.51,410.11,,512.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,145.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,145.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,512.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,615.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,512.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,512.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,430.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,140.05,615.16,
DEBRIDEMENT SKIN/ MUSC,2810011,CDM,510,RC,11043,HCPCS,outpatient,,,1142.71,685.63,,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,914.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,664.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,243.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,243.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,245.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,521.2,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1028.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,857.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,234.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,719.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,234.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,510.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,234.14,1459.9,
DEBRIDEMENT SKIN/ MUSC/BONE,2810012,CDM,510,RC,11044,HCPCS,outpatient,,,3117.55,1870.53,,2338.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2494.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1714.66,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,664.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,664.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,670.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1345.35,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2805.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2338.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2338.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2338.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2338.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,638.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1964.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,638.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1318.97,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,638.79,2805.8,
FLUSH VENOUS ACCESS,1000027,CDM,510,RC,96523,HCPCS,outpatient,,,137.41,82.45,,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,109.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,29.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.54,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,123.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,86.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.16,123.67,
Outpatient visit of established patient not requiring a physician,2810002,CDM,510,RC,99211,HCPCS,outpatient,,,228.1,136.86,,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,205.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,171.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,143.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.74,205.29,
Outpatient visit of established patient requiring a physician,2810003,CDM,510,RC,99212,HCPCS,outpatient,,,248.6,149.16,,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,223.74,
"Established patient office or other outpatient visit, typically 15 minutes",2810004,CDM,510,RC,99213,HCPCS,outpatient,,,310.61,186.37,,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.64,279.55,
"Established patient office or other outpatient visit, typically 25 minutes",2810005,CDM,510,RC,99214,HCPCS,outpatient,,,372.89,223.73,,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,234.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,335.6,
"Established patient office or other outpatient, visit typically 40 minutes",2810006,CDM,510,RC,99215,HCPCS,outpatient,,,434.91,260.95,,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,273.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.11,391.42,
INJECTION,2810034,CDM,510,RC,96372,HCPCS,outpatient,,,92.34,55.4,,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,19.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,83.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,69.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,58.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.92,83.11,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",2810033,CDM,510,RC,96365,HCPCS,outpatient,,,453.76,272.26,,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,96.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,408.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,285.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,408.38,
"New patient office of other outpatient visit, typically 60 min",2810001,CDM,510,RC,99205,HCPCS,outpatient,,,621.48,372.89,,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,497.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.62,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,559.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,466.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,391.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,127.34,559.33,
"New patient office of other outpatient visit, typically 45 min",2810028,CDM,510,RC,99204,HCPCS,outpatient,,,372.89,223.73,,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,298.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,80.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,335.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,279.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,234.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.41,335.6,
NEW PATIENT LEVEL ONE,2810025,CDM,510,RC,99201,HCPCS,outpatient,,,185.49,111.29,,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,116.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.01,166.94,
"New patient office or other outpatient visit, typically 30 min",2810027,CDM,510,RC,99203,HCPCS,outpatient,,,310.61,186.37,,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.49,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,279.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,195.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.64,279.55,
"New patient office or other outpatient visit, typically 10 minutes",2810026,CDM,510,RC,99202,HCPCS,outpatient,,,248.6,149.16,,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,52.95,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.94,223.74,
SEMMES WEINSTEIN MONOFILAMENT,2810022,CDM,510,RC,,,outpatient,,,74.58,44.75,,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.12,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,46.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.28,67.12,
UNNA BOOT APP BILATERAL,2810032,CDM,510,RC,2958050,HCPCS,outpatient,,,418.79,251.27,,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,335.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,376.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,314.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,263.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.81,376.91,
UNNA BOOT APP LT,2810023,CDM,510,RC,29580LT,HCPCS,outpatient,,,315.25,189.15,,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,67.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,198.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,1459.9,
UNNA BOOT APP RT,2810035,CDM,510,RC,29580RT,HCPCS,outpatient,,,315.25,189.15,,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,252.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,67.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,67.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,283.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,236.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,198.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.59,1459.9,
WOUND BIOPSY,2810014,CDM,510,RC,,,outpatient,,,273.45,164.07,,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,58.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,246.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,172.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,56.03,246.11,
WOUND BIOPSY ADD'L,2810015,CDM,510,RC,11100,HCPCS,outpatient,,,737.87,442.72,,553.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,590.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,157.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,553.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,664.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,553.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,553.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,464.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,151.19,664.08,
WOUND CAUTERY CHEMICAL,2810013,CDM,510,RC,,,outpatient,,,149.16,89.5,,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.33,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,134.24,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,93.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.56,134.24,
WOUND CLINIC PROCEDURES,1000009,CDM,510,RC,,,outpatient,,,1069.24,641.54,,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,855.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,227.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,962.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,801.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,673.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,219.09,962.32,
"New patient office or other outpatient visit, typically 30 min",1750005,CDM,514,RC,99203,HCPCS,outpatient,,,271.27,162.76,,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,170.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,244.14,
ACLS 2,2940003,CDM,540,RC,A0433,HCPCS,outpatient,,,1128.51,677.11,,846.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,902.81,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,240.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,846.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,242.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1015.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,846.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,846.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,231.23,1156,
ALS-BASE RATE ONE WAY,2940001,CDM,540,RC,A0427,HCPCS,outpatient,,,715.46,429.28,,536.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,572.37,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,152.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,152.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,536.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,643.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,536.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,536.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,536.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,536.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,146.6,1156,
ALS-ROUND TRIP,2940002,CDM,540,RC,,,outpatient,,,1429.84,857.9,,1072.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1143.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,304.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,304.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1072.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1286.86,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1072.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1072.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,292.97,1286.86,
AMB MILEAGE NON-COV,2960007,CDM,540,RC,,,outpatient,,,13.67,8.2,,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,1156,
AMB MISC MILEAGE,2950015,CDM,540,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1156,1156,
AMB W/T PER 1/2 HR,2950008,CDM,540,RC,,,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,1156,
AMBULANCE ALS MILEAGE,2950009,CDM,540,RC,A0425,HCPCS,outpatient,,,15.3,9.18,,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,1156,
AMBULANCE BLS MILEAGE,2950007,CDM,540,RC,A0425,HCPCS,outpatient,,,15.3,9.18,,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.77,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,1156,
BLS NON EMER,2950002,CDM,540,RC,A0429,HCPCS,outpatient,,,951.49,570.89,,713.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,761.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,202.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,202.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,713.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,204.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,713.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,713.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,713.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,713.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.96,1156,
BLS-BASE RATE-ONE WAY,2950001,CDM,540,RC,A0429,HCPCS,outpatient,,,635.15,381.09,,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,135.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,135.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,136.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,571.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,130.14,1156,
EMS OUT OF CNTY MILES,2960005,CDM,540,RC,,,outpatient,,,13.67,8.2,,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.8,1156,
EMS OXYGEN SETUP and USE,2960003,CDM,540,RC,,,outpatient,,,90.42,54.25,,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.53,1156,
EMS TRANSPORT 1-WAY,2960001,CDM,540,RC,,,outpatient,,,342.58,205.55,,256.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,72.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,256.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,308.32,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,256.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.19,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.19,1156,
EMS TRANSPORT 2-WAY,2960002,CDM,540,RC,,,outpatient,,,356.23,213.74,,267.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,284.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,267.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,320.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,267.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,267.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.99,1156,
EMS WAITING TIME 1/2 HR,2960006,CDM,540,RC,,,outpatient,,,43.98,26.39,,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.01,1156,
MISC AMBULANCE,2950014,CDM,540,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1156,1156,
MISC EMS,2960004,CDM,540,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,1156,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1156,1156,
AMBULANCE O2 SETUP and USAGE,2950003,CDM,544,RC,A0422,HCPCS,outpatient,,,90.42,54.25,,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.53,81.38,
MRI of abdomen without dye,1620016,CDM,610,RC,74181,HCPCS,outpatient,,,2721.7,1633.02,,2041.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2177.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,579.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,579.72,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2041.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,585.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2449.53,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2041.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2041.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2041.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2041.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,557.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,557.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2449.53,
MRA ABD W/ OR W/O,1620052,CDM,610,RC,74185,HCPCS,outpatient,,,3052.54,1831.52,,2289.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2442.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,650.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,650.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2289.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,656.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2747.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2289.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2289.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2289.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2289.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,625.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,774.22,160,,,fee schedule,160% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,625.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,625.47,2747.29,
MRA BILAT LOWER EXT W OR WO CONTRAST,1620049,CDM,610,RC,73725,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,769.62,160,,,fee schedule,160% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRA CHEST WITH AND WITHOUT CONTRAST,1620078,CDM,610,RC,71555,HCPCS,outpatient,,,3293.48,1976.09,,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2634.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,701.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,701.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2964.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,674.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,764.06,160,,,fee schedule,160% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,674.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,674.83,2964.13,
MRA CHEST WITH CONTRAST,1620031,CDM,610,RC,71555,HCPCS,outpatient,,,3235.84,1941.5,,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,689.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,695.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2912.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,764.06,160,,,fee schedule,160% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.02,2912.26,
MRA CHEST WITHOUT CONTRAST,1620077,CDM,610,RC,71555,HCPCS,outpatient,,,2572,1543.2,,1929,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2057.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,547.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,547.84,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1929,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,552.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2314.8,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1929,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1929,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1929,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1929,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,764.06,160,,,fee schedule,160% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,527,2314.8,
MRA PELVIS W & W/O CONTRAST,1620039,CDM,610,RC,72198,HCPCS,outpatient,,,3132.57,1879.54,,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2506.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,667.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,667.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2819.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,770.53,160,,,fee schedule,160% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,641.86,2819.31,
MRA UPPER EXT W/ OR W/O,1620044,CDM,610,RC,73225,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,800.1,160,,,fee schedule,160% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI ABDOMEN W/,1620050,CDM,610,RC,74182,HCPCS,outpatient,,,3132.57,1879.54,,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2506.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,667.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,667.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2819.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,641.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,641.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2819.31,
MRI of abdomen without and with dye,1620051,CDM,610,RC,74183,HCPCS,outpatient,,,3695.6,2217.36,,2771.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2956.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,787.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,787.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2771.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3326.04,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2771.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2771.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2771.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2771.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,757.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,757.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,3326.04,
MRI of abdomen without dye,1620004,CDM,610,RC,74181,HCPCS,outpatient,,,2668.72,1601.23,,2001.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2134.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,568.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,568.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2001.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,573.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2401.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2001.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2001.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2001.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2001.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,546.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,546.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2401.85,
MRI CHEST W/ & W/O,1620030,CDM,610,RC,71552,HCPCS,outpatient,,,3235.84,1941.5,,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,689.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,695.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2912.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,663.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2912.26,
MRI CHEST W/O,1620006,CDM,610,RC,71550,HCPCS,outpatient,,,2540.05,1524.03,,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2032.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,541.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,541.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2286.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2286.05,
MRI CHEST WITH,1620029,CDM,610,RC,71551,HCPCS,outpatient,,,3182.83,1909.7,,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,651.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,847,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,664.57,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2864.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,651.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,651.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1742.9,160,,,fee schedule,160% UHC fee schedule for outpatient setting,651.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,651.54,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,651.54,2864.55,
MRI LOWER EXT JT W/ WO CONTRAST BILAT,1620075,CDM,610,RC,7372350,HCPCS,outpatient,,,5047.58,3028.55,,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4038.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1075.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1085.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4542.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2523.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.25,4542.82,
MRI LOWER EXT JT W/ WO CONTRAST LT,1620048,CDM,610,RC,73723LT,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI LOWER EXT JT W/ WO CONTRAST RT,1620074,CDM,610,RC,73723RT,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI LOWER EXT JT WITH CONTRAST BILAT,1620073,CDM,610,RC,7372250,HCPCS,outpatient,,,4170.4,2502.24,,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3336.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,888.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,888.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,896.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3753.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2085.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.51,3753.36,
MRI LOWER EXT JT WITH CONTRAST LT,1620047,CDM,610,RC,73722LT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI LOWER EXT JT WITH CONTRAST RT,1620072,CDM,610,RC,73722RT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI of lower extremity joint (knee/ankle) without dye,1620071,CDM,610,RC,73721,HCPCS,outpatient,,,3507.38,2104.43,,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2805.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,747.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,747.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3156.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,718.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,718.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,3156.64,
MRI LOWER EXT JT WITHOUT CONTRAST LT,1620007,CDM,610,RC,73721LT,HCPCS,outpatient,,,2365.01,1419.01,,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1892.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,503.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2128.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1182.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.59,2128.51,
MRI LOWER EXT JT WITHOUT CONTRAST RT,1620070,CDM,610,RC,73721RT,HCPCS,outpatient,,,2365.01,1419.01,,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1892.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,503.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2128.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1182.51,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,484.59,2128.51,
MRI LOWER EXT W/O CONTRAST BILAT,1620005,CDM,610,RC,7371850,HCPCS,outpatient,,,3507.38,2104.43,,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2805.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,747.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,747.07,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.09,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3156.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2630.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1753.69,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.66,3156.64,
MRI LOWER EXT W/O LT,1620045,CDM,610,RC,73718LT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI LOWER EXT W/O RT,1620003,CDM,610,RC,73718RT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI LOWER EXT W/WO CONTRAST BILAT,1620069,CDM,610,RC,7372050,HCPCS,outpatient,,,5047.58,3028.55,,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4038.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1075.13,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1085.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4542.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3785.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2523.79,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1034.25,4542.82,
MRI LOWER EXT W/WO CONTRAST LT,1620008,CDM,610,RC,73720LT,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI LOWER EXT W/WO CONTRAST RT,1620068,CDM,610,RC,73720RT,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI LOWER EXT WITH CONTRAST BILAT,1620067,CDM,610,RC,7371950,HCPCS,outpatient,,,4170.4,2502.24,,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3336.32,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,888.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,888.3,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,896.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3753.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3127.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2085.2,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,854.51,3753.36,
MRI LOWER EXT WITH CONTRAST LT,1620046,CDM,610,RC,73719LT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI LOWER EXT WITH CONTRAST RT,1620010,CDM,610,RC,73719RT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI of lower back with and without dye,1620036,CDM,610,RC,72158,HCPCS,outpatient,,,3182.83,1909.7,,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2864.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2864.55,
MRI scan of lower spinal canal,1620009,CDM,610,RC,72148,HCPCS,outpatient,,,3665.77,2199.46,,2749.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2932.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,780.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,780.81,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2749.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,788.14,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3299.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2749.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2749.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2749.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2749.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,751.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,751.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,3299.19,
MRI LUMBAR WITH CONTRAST,1620017,CDM,610,RC,72149,HCPCS,outpatient,,,2731.54,1638.92,,2048.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2185.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,581.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,581.82,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2048.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2458.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2048.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2048.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2048.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2048.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,559.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,559.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2458.39,
MRI of abdomen without dye,1620081,CDM,610,RC,74181,HCPCS,outpatient,,,2973.86,1784.32,,2230.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2379.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,633.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,633.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2230.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2676.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2230.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2230.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2230.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2230.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,609.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,609.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2676.47,
"MRI ORBIT,FACE,NECK W/O",1620018,CDM,610,RC,70540,HCPCS,outpatient,,,2540.05,1524.03,,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2032.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,541.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,541.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2286.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2286.05,
"MRI ORBIT,FACE,NECK W/O & WITH",1620024,CDM,610,RC,70543,HCPCS,outpatient,,,3182.83,1909.7,,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2864.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2864.55,
"MRI ORBIT,FACE,NECK WITH",1620023,CDM,610,RC,70542,HCPCS,outpatient,,,2540.05,1524.03,,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2032.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,541.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,541.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2286.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2286.05,
MRI of pelvis before and after dye,1620038,CDM,610,RC,72197,HCPCS,outpatient,,,3132.57,1879.54,,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2506.06,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,667.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,667.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2819.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2349.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,641.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,641.86,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2819.31,
MRI of pelvis without dye,1620020,CDM,610,RC,72195,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2192.36,
MRI PELVIS WITH CONTRAST,1620002,CDM,610,RC,72196,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2385.38,
MRI of chest and spine with and without dye,1620035,CDM,610,RC,72157,HCPCS,outpatient,,,3293.48,1976.09,,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2634.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,701.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,701.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,708.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2964.13,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2470.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,674.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,674.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2964.13,
MRI of chest and spine without dye,1620011,CDM,610,RC,72146,HCPCS,outpatient,,,2540.05,1524.03,,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2032.04,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,541.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,541.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,546.11,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2286.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1905.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,520.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2286.05,
MRI THORACIC WITH CONTRAST,1620034,CDM,610,RC,72147,HCPCS,outpatient,,,2811.59,1686.95,,2108.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2249.27,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,598.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,598.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2108.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,604.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2530.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2108.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2108.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2108.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2108.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,576.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,576.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2530.43,
MRI UPPER EXT JT W/O CONTRAST BILAT,1620062,CDM,610,RC,7322150,HCPCS,outpatient,,,4018.77,2411.26,,3014.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3215.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,856,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,856,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3014.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,864.04,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3616.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3014.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3014.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3014.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3014.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,823.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2009.39,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,823.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,823.45,3616.89,
MRI UPPER EXT JT W/O CONTRAST LT,1620012,CDM,610,RC,73221LT,HCPCS,outpatient,,,2009.53,1205.72,,1507.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1607.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,428.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,428.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1507.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,432.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1808.58,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1507.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1507.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1004.77,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.75,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,411.75,1808.58,
MRI UPPER EXT JT W/O CONTRAST RT,1620061,CDM,610,RC,73221RT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI UPPER EXT JT W/WO CONTRAST BILAT,1620066,CDM,610,RC,7322350,HCPCS,outpatient,,,5193.73,3116.24,,3895.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4154.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1106.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1106.26,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1116.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4674.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3895.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3895.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3895.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3895.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1064.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2596.87,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1064.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1064.2,4674.36,
MRI UPPER EXT JT W/WO CONTRAST LT,1620043,CDM,610,RC,73223LT,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI UPPER EXT JT W/WO CONTRAST RT,1620065,CDM,610,RC,73223LT,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI UPPER EXT JT WITH CONTRAST BILAT,1620064,CDM,610,RC,7322250,HCPCS,outpatient,,,4739.98,2843.99,,3554.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3791.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1009.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1009.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3554.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1019.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4265.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3554.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3554.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3554.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3554.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,971.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2369.99,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,971.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,971.22,4265.98,
MRI UPPER EXT JT WITH CONTRAST LT,1620042,CDM,610,RC,73222LT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI UPPER EXT JT WITH CONTRAST RT,1620063,CDM,610,RC,73222RT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI UPPER EXT W & W/O CONTRAST BILAT,1620060,CDM,610,RC,7322050,HCPCS,outpatient,,,5092.93,3055.76,,3819.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4074.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1084.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1084.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1094.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4583.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3819.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3819.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3819.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3819.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2546.47,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1043.54,4583.64,
MRI UPPER EXT W & W/O CONTRAST LT,1620013,CDM,610,RC,73220LT,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI UPPER EXT W & W/O CONTRAST RT,1620059,CDM,610,RC,73220RT,HCPCS,outpatient,,,2650.42,1590.25,,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2120.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,564.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,569.84,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2385.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1987.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1325.21,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,543.07,2385.38,
MRI UPPER EXT W/O CONTRAST BILAT,1620056,CDM,610,RC,7321850,HCPCS,outpatient,,,3361.23,2016.74,,2520.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2688.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,715.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,715.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2520.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,722.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3025.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2520.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2520.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2520.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2520.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1680.62,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,688.72,3025.11,
MRI UPPER EXT W/O CONTRAST LT,1620055,CDM,610,RC,73218LT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI UPPER EXT W/O CONTRAST RT,1620040,CDM,610,RC,73218RT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI UPPER EXT WITH CONTRAST BILAT,1620058,CDM,610,RC,7321950,HCPCS,outpatient,,,4024.24,2414.54,,3018.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3219.39,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,857.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,857.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3018.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.21,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3621.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3018.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3018.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3018.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3018.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,824.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2012.12,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,824.57,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,824.57,3621.82,
MRI UPPER EXT WITH CONTRAST LT,1620041,CDM,610,RC,73219LT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRI UPPER EXT WITH CONTRAST RT,1620057,CDM,610,RC,73219RT,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1217.98,50,,,percent of total billed charges,50% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,499.13,2192.36,
MRA HEAD W/O,1620022,CDM,611,RC,70544,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2192.36,
MRA HEAD WITH,1620025,CDM,611,RC,70545,HCPCS,outpatient,,,2618.45,1571.07,,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2094.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,557.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,557.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2356.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,536.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,536.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2356.61,
MRA HEAD WITH & W/O,1620026,CDM,611,RC,70546,HCPCS,outpatient,,,3182.83,1909.7,,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2864.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2864.55,
MRA NECK W/,1620027,CDM,611,RC,70548,HCPCS,outpatient,,,2618.45,1571.07,,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2094.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,557.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,557.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2356.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,536.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,536.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2356.61,
MRA NECK W/ & W/O,1620028,CDM,611,RC,70549,HCPCS,outpatient,,,3182.83,1909.7,,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2864.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2864.55,
MRA NECK W/O,1620021,CDM,611,RC,70547,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2192.36,
MRA SPINAL CANAL W/ & W/O,1620037,CDM,611,RC,72159,HCPCS,outpatient,,,3235.84,1941.5,,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2588.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,689.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,689.23,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,695.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2912.26,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2426.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,800.1,160,,,fee schedule,160% UHC fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,663.02,2912.26,
MRI scan of brain before and after contrast,1620019,CDM,611,RC,70553,HCPCS,outpatient,,,3182.83,1909.7,,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2864.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2864.55,
MRI BRAIN WITH CONTRAST,1620000,CDM,611,RC,70552,HCPCS,outpatient,,,2618.45,1571.07,,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2094.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,557.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,557.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2356.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,536.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,536.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2356.61,
MRI of brain stem without dye,1620014,CDM,611,RC,70551,HCPCS,outpatient,,,2435.96,1461.58,,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1948.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,518.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,523.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2192.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1826.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,499.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2192.36,
MRI of the neck or spine without dye,1620015,CDM,612,RC,72141,HCPCS,outpatient,,,2365.01,1419.01,,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1892.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,503.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,503.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2128.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1773.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,484.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,596.58,160,,,fee schedule,160% UHC fee schedule for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,484.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,2128.51,
MRI of neck/spine with and without dye,1620033,CDM,612,RC,72156,HCPCS,outpatient,,,3182.83,1909.7,,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2546.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,677.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,684.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2864.55,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2387.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,652.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2864.55,
MRI CERVICAL SPINE WITH CONTRAST,1620032,CDM,612,RC,72142,HCPCS,outpatient,,,2618.45,1571.07,,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2094.76,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,421.27,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,557.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,557.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,562.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,330.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2356.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1963.84,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,536.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,977.54,160,,,fee schedule,160% UHC fee schedule for outpatient setting,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,536.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,324.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,324.06,2356.61,
ACETAMINOPHEN (OFIRMEV) 10MG/ML 100ML PB,1404014,CDM,636,RC,J0131,HCPCS,both,,,195.32,117.19,,146.49,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,146.49,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.2,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,41.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,156.26,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,146.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,146.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,123.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,156.26,
ACETYLCYSTEINE(ACETADOTE)200MG/ML INJ 30,1402457,CDM,636,RC,J0132,HCPCS,both,,,852.6,511.56,,639.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,639.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,181.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,181.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.55,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,183.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,682.08,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,639.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,639.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,537.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,174.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,682.08,
ACTEMRA (TOCILZUMAB) 400MG/20ML VIAL,1404697,CDM,636,RC,J3262,HCPCS,both,,,2652.25,1591.35,,1989.19,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,1989.19,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.8,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2121.8,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,1989.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1989.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1989.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1989.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,1670.92,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.8,2121.8,
ACTEMRA (TOCILZUMAB) 800MG / 100ML NS,1404698,CDM,636,RC,J3262,HCPCS,both,,,132.61,79.57,,99.46,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,99.46,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.02,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,7.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.47,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.8,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.31,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,106.09,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,99.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,83.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.19,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.8,106.09,
ACYCLOVIR (ZOVIRAX) 500MG INJ,1401185,CDM,636,RC,J0133,HCPCS,both,,,36.34,21.8,,27.26,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,27.26,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.07,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.07,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,29.07,
ADENOSINE (ADENOCARD) 6MG/2ML INJ,1401655,CDM,636,RC,J0153,HCPCS,both,,,60.1,36.06,,45.08,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,45.08,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.47,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.53,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.08,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,37.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.47,48.08,
ALBUMIN 25% 25GM/100ML INJ,1401969,CDM,636,RC,P9047,HCPCS,both,,,318.27,190.96,,238.7,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,238.7,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,63.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,63.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.45,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,63.73,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,54.14,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,254.62,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,238.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,200.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,63.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,53.08,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,52.45,254.62,
ALPROSTADIL INJ 500MCG,1402454,CDM,636,RC,J0270,HCPCS,both,,,668.58,401.15,,501.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,501.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,142.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,142.41,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.49,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,143.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,534.86,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,501.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,501.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,421.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.99,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.49,534.86,
ALTEPLASE (ACTIVASE) 100MG INJ,1401585,CDM,636,RC,J2997,HCPCS,both,,,19873.71,11924.23,,14905.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,14905.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.9,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,4233.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4233.1,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,85.82,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4272.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,90.94,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,15898.97,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,14905.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14905.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14905.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14905.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4072.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12520.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4072.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,89.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.82,15898.97,
AMIKACIN 250MG/ML (2ML),1402759,CDM,636,RC,J0278,HCPCS,both,,,49.45,29.67,,37.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,37.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.8,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.56,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,31.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.8,39.56,
AMINOPHYLLINE 250MG INJ 10ML,1400059,CDM,636,RC,J0280,HCPCS,both,,,81.89,49.13,,61.42,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,61.42,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.51,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,61.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,51.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,65.51,
AMINOPHYLLINE 250MG/ML INJ 20ML,1404725,CDM,636,RC,J0280,HCPCS,both,,,81.89,49.13,,61.42,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,61.42,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.51,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,61.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,51.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.22,65.51,
AMIODARONE (CORDARONE) 50MG/ML 3ML INJ,1402158,CDM,636,RC,J0282,HCPCS,both,,,6.5,3.9,,4.88,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.88,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.43,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.2,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.33,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,5.2,
AMIODARONE (CORDARONE) 900MG/18ML,1404630,CDM,636,RC,J0282,HCPCS,both,,,51.91,31.15,,38.93,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,38.93,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.43,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,11.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.53,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,41.53,
AMIODARONE:450MG/D5W 250ML,1402802,CDM,636,RC,J0282,HCPCS,both,,,170.28,102.17,,127.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,127.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,36.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.43,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,36.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,136.22,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,127.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,107.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.89,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,136.22,
AMIODARONE(CORDARONE) 1800MG/1000ML D5W,5927,CDM,636,RC,J0282,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.43,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,0.43,
AMOXICILLIN (AMOXIL)250MG/5ML100ML SUSP,1402601,CDM,636,RC,J3490,HCPCS,both,,,6.02,3.61,,4.52,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.52,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.28,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.23,4.82,
AMPICILLIN 125MG /NS 25ML IVPB,1402808,CDM,636,RC,J0290,HCPCS,both,,,19.89,11.93,,14.92,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,14.92,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.91,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,15.91,
AMPICILLIN 1GM/NS 100ML IVPB,1402787,CDM,636,RC,J0290,HCPCS,both,,,27.59,16.55,,20.69,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,20.69,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.07,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,22.07,
AMPICILLIN 250MG VIAL,1400066,CDM,636,RC,J0290,HCPCS,both,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,4.37,
AMPICILLIN 250MG/NS 50ML IVPB,1402815,CDM,636,RC,J0290,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,0.92,
AMPICILLIN 2GM VIAL,1400065,CDM,636,RC,J0290,HCPCS,both,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,10.06,
AMPICILLIN 2GM/NS 100ML IVBP,1402799,CDM,636,RC,J0290,HCPCS,both,,,73.49,44.09,,55.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,55.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.79,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,46.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,58.79,
AMPICILLIN 500MG VIAL,1401113,CDM,636,RC,J0290,HCPCS,both,,,7.59,4.55,,5.69,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.69,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.07,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,6.07,
AMPICILLIN 500MG/NS 100ML IVPB,1402788,CDM,636,RC,J0290,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,0.92,
AMPICILLIN 500MG/NS 50ML IVPB,1402786,CDM,636,RC,J0290,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,0.92,
AMPICILLIN/SUB (UNASYN) 1.5GM VIAL,1401773,CDM,636,RC,J0295,HCPCS,both,,,28.96,17.38,,21.72,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,21.72,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.17,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,23.17,
AMPICILLIN/SUB (UNASYN) 3GM VIAL,1401828,CDM,636,RC,J0295,HCPCS,both,,,25.46,15.28,,19.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,19.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,20.37,
AMPICILLIN/SULB 1.5GM/NS100ML IVPB,1402825,CDM,636,RC,J0295,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,3.2,
ATROPINE 0.4MG/ML 20 ML MDV,1404077,CDM,636,RC,J2001,HCPCS,both,,,34.15,20.49,,25.61,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,25.61,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.32,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,27.32,
ATROPINE 0.4MG/ML INJ,1400098,CDM,636,RC,J0461,HCPCS,both,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.08,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.62,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,9.62,
ATROPINE 1MG/10ML ABBJ,1401192,CDM,636,RC,J0461,HCPCS,both,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,33.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.08,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.41,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,35.41,
ATROPINE PED INJ 0.05MG/ML SYRINGE,1401588,CDM,636,RC,J0461,HCPCS,both,,,38.99,23.39,,29.24,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,29.24,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.08,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.19,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.08,31.19,
AZATHIOPRINE (IMURAN) 50MG TAB,1401061,CDM,636,RC,J7500,HCPCS,both,,,4.24,2.54,,3.18,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.18,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.15,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.39,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,9.15,
AZITHROMYCIN(ZITHROMAX) 500MG VIAL,1402137,CDM,636,RC,J0456,HCPCS,both,,,9.29,5.57,,6.97,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,6.97,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.43,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,5.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.9,7.43,
BAMLANIVIMAB 700MG INJ,1404671,CDM,636,RC,Q0239,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
BAMLANIVIMAB 700MG/50ML NS,1404672,CDM,636,RC,Q0239,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
BAMLANIVIMAB 700MG/ETESEVIMAB 1400MG/NS,1404682,CDM,636,RC,Q0239,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
BB RHOGAM IMMUNE GLOBULIN,1500067,CDM,636,RC,90384,HCPCS,both,,,438.74,263.24,,329.06,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,329.06,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.57,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,94.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,350.99,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,329.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,276.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.57,350.99,
BENZTROPINE (COGENTIN) 1MG/ML INJ 2ML,1400270,CDM,636,RC,J0515,HCPCS,both,,,214.18,128.51,,160.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,160.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.71,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,18.03,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,17.74,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.34,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,160.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,134.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.59,171.34,
BUTORPHANOL (STADOL) 2MG/ML INJ,1400587,CDM,636,RC,J0595,HCPCS,both,,,21.72,13.03,,16.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,16.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.97,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.38,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,16.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,17.38,
CALCIUM CHLORIDE 1GM/10ML ABBJ,1400522,CDM,636,RC,J0610,HCPCS,both,,,39.61,23.77,,29.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,29.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.41,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.69,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,31.69,
CALCIUM GLUCONATE 1GM/10ML INJ,1400127,CDM,636,RC,J0610,HCPCS,both,,,42.44,25.46,,31.83,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,31.83,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.41,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.41,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.42,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.95,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.96,33.95,
CEFAZOLIN : 500MG INJ (VIAL),1400319,CDM,636,RC,J0690,HCPCS,both,,,22.28,13.37,,16.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,16.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,16.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,17.82,
CEFAZOLIN (ANCEF) 1GM 50ML PREMIXED,1404004,CDM,636,RC,J0690,HCPCS,both,,,44.03,26.42,,33.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,33.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.22,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,35.22,
CEFAZOLIN (ANCEF) 2GM 50ML PREMIX,1403396,CDM,636,RC,J0690,HCPCS,both,,,47.27,28.36,,35.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,35.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,37.82,
CEFAZOLIN (ANCEF): IVPB 2000MG/NS 50ML,1403848,CDM,636,RC,J0690,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,0.87,
CEFAZOLIN (ANCEF)1GM/NS 50ML IVPB,1402810,CDM,636,RC,J0690,HCPCS,both,,,12.3,7.38,,9.23,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.23,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,9.84,
CEFAZOLIN:1000MG INJ/D5W 50ML (FROZEN),1401713,CDM,636,RC,J0690,HCPCS,both,,,44.03,26.42,,33.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,33.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.22,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,35.22,
CEFAZOLIN(ANCEF) 1GM VIAL,1400318,CDM,636,RC,J0690,HCPCS,both,,,6.02,3.61,,4.52,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.52,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,4.82,
CEFEPIME (MAXIPIME) 1GM VIAL,1402618,CDM,636,RC,J0692,HCPCS,both,,,21.31,12.79,,15.98,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,15.98,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.05,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,17.05,
CEFEPIME (MAXIPIME) 1GM/NS 50ML IVPB,1402822,CDM,636,RC,J0692,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,1.78,
CEFEPIME (MAXIPIME) 2GM VIAL,1402739,CDM,636,RC,J0692,HCPCS,both,,,24.85,14.91,,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.88,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,19.88,
CEFEPIME (MAXIPIME) 2GM/NS 100ML IVPB,1402823,CDM,636,RC,J0692,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,1.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,1.78,
CEFOTAXIME:1000MG INJ (VIAL),1400890,CDM,636,RC,J0698,HCPCS,both,,,51.46,30.88,,38.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,38.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.8,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,11.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.17,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,38.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,32.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.8,41.17,
CEFOTAXIME:1000MG/NS 100ML IVPB,1402818,CDM,636,RC,J0698,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.8,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,11.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.8,11.91,
CEFOTAXIME:2000MG /NS 100ML IVPB,1402819,CDM,636,RC,J0698,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.8,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,11.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.8,11.91,
CEFOTAXIME:2000MG INJ (VIAL),1401476,CDM,636,RC,J0698,HCPCS,both,,,187.51,112.51,,140.63,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,140.63,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.8,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,11.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,140.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,140.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,118.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.8,150.01,
CEFOXITIN (MEFOXIN) 2GM/100ML IVPB,1402793,CDM,636,RC,J0694,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.63,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.45,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,6.45,
CEFOXITIN (MEFOXIN)2GM/D5W 50ML PREMIXED,5663,CDM,636,RC,J0690,HCPCS,both,,,120.48,72.29,,90.36,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,90.36,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.87,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.38,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,75.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,96.38,
CEFOXITIN:2000MG INJ (VIAL),1400384,CDM,636,RC,J0692,HCPCS,both,,,105.03,63.02,,78.77,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,78.77,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,22.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.02,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,78.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.78,84.02,
CEFOXITIN(MEFOXIN) 1GM VIAL,1400383,CDM,636,RC,J0694,HCPCS,both,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.63,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.45,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,10.06,
CEFOXITIN(MEFOXIN) 1GM/NS 50ML IVPB,1402779,CDM,636,RC,J0694,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.63,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.45,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.4,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.63,6.45,
CEFTAZIDIME (FORTAZ) 1GM/NS 100ML IVPB,1402820,CDM,636,RC,J0713,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,2.09,
CEFTAZIDIME (TAZICEF) 1GM VIAL,1400259,CDM,636,RC,J0713,HCPCS,both,,,16.94,10.16,,12.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.55,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,13.55,
CEFTAZIDIME (TAZICEF) 2GM VIAL,1404742,CDM,636,RC,J0713,HCPCS,both,,,34.76,20.86,,26.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,26.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.47,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.81,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,26.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,27.81,
CEFTAZIDIME: 2000MG INJ (VIAL),1402584,CDM,636,RC,J0713,HCPCS,both,,,100.26,60.16,,75.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,75.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,21.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,80.21,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,75.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,63.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,80.21,
CEFTAZIDIME: 2000MG/NS 100ML IVPB,1402821,CDM,636,RC,J0713,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,2.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.09,2.09,
CEFTRIAXONE (ROCEPHIN 1GM/50ML NS IVPB,1402829,CDM,636,RC,J0715,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
CEFTRIAXONE (ROCEPHIN) 1GM VIAL,1401112,CDM,636,RC,J0696,HCPCS,both,,,16.39,9.83,,12.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.11,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,13.11,
CEFTRIAXONE (ROCEPHIN) 250MG VIAL,1401177,CDM,636,RC,J0696,HCPCS,both,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,3.5,
CEFTRIAXONE (ROCEPHIN) 250MG/50ML NS PB,1402784,CDM,636,RC,J0696,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,0.61,
CEFTRIAXONE (ROCEPHIN) 2GM 50ML PREMIXED,1404068,CDM,636,RC,J0696,HCPCS,both,,,199.7,119.82,,149.78,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,149.78,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.76,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,125.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,159.76,
CEFTRIAXONE (ROCEPHIN) 2GM VIAL,1402238,CDM,636,RC,J0696,HCPCS,both,,,79.57,47.74,,59.68,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,59.68,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.66,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,63.66,
CEFTRIAXONE (ROCEPHIN) 2GM/100ML NS IVPB,1402830,CDM,636,RC,J0715,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
CEFTRIAXONE (ROCEPHIN) 500MG VIAL,1401178,CDM,636,RC,J0696,HCPCS,both,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,3.5,
CEFTRIAXONE (ROCEPHIN) 500MG/50ML NS PB,1402795,CDM,636,RC,J0696,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,0.61,
CEFTRIAXONE 1000MG/NS 100ML IVPB,1402812,CDM,636,RC,,,both,,,215.04,129.02,,161.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,161.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,45.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,161.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.03,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,161.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,161.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,135.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.06,172.03,
CEFTRIAXONE 2000MG/NS 100ML IVPB,1402814,CDM,636,RC,,,both,,,300.13,180.08,,225.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,225.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,63.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,240.1,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,189.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.5,240.1,
CEFTRIAXONE:1000MG IVPB (FROZEN),1402057,CDM,636,RC,J0696,HCPCS,both,,,193.88,116.33,,145.41,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,145.41,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.1,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,122.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,155.1,
CEFTRIAXONE:2000MG INJ/D5W 50ML (FROZEN),1402569,CDM,636,RC,J0696,HCPCS,both,,,193.88,116.33,,145.41,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,145.41,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,155.1,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,122.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,155.1,
CEFTRIAXONE(ROCEPHIN)1GM/50ML D5W PREMIX,1404039,CDM,636,RC,J0696,HCPCS,both,,,30.6,18.36,,22.95,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,22.95,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.48,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.51,24.48,
CEREBYX: 1000MG/NS 100ML IVPB,1402839,CDM,636,RC,Q2009,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,4.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.75,4.75,
CHLORPROMAZINE (THORAZINE) 25MG/ML INJ,1400643,CDM,636,RC,J3230,HCPCS,both,,,58.89,35.33,,44.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,44.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,41.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.28,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,41.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.11,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,44.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,37.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.28,47.11,
CIPROFLOXACIN (CIPRO) 200MG/100ML D5W PM,1402134,CDM,636,RC,J0744,HCPCS,both,,,12.02,7.21,,9.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.1,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.62,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.46,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.1,9.62,
CONJUGATED ESTROGEN INJ 25MG,1400507,CDM,636,RC,J1410,HCPCS,both,,,328.37,197.02,,246.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,246.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,484.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,431.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,431.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,353.67,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,431.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,379.92,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,262.7,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,246.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,428.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,206.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,428.33,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,372.48,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,206.87,484.22,
CORDARONE(AMIODARONE) 150MG/100ML D5W,1404708,CDM,636,RC,J0282,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.43,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,0.43,
CORDARONE(AMIODARONE) 1800MG/500ML D5W,5929,CDM,636,RC,J0282,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.43,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,0.43,
CORDARONE(AMIODARONE) 900MG/500ML D5W DR,1404022,CDM,636,RC,J0282,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.43,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.43,0.43,
COSYNTROPIN*INJ 0.25MG **,1402424,CDM,636,RC,J0834,HCPCS,both,,,957.51,574.51,,718.13,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,718.13,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,37.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.95,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,37.74,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,766.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,718.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,718.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,603.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.42,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.95,766.01,
"COVID-19 VACCINE (ASTAZENECA), 5X1010 PA",1404677,CDM,636,RC,91302,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
"COVID-19 VACCINE (MODERNA), 100MCG",1404676,CDM,636,RC,91301,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
"COVID-19 VACCINE (PFIZER), 30MCG",1404675,CDM,636,RC,91300,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
CYANOCOBALAMIN (VITAMIN B12) 1MG/ML INJ,1400115,CDM,636,RC,J3420,HCPCS,both,,,28.12,16.87,,21.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,21.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.57,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.37,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,22.5,
CYANOCOBALAMIN: 1MG/ML INJ 30ML,1404013,CDM,636,RC,J3420,HCPCS,both,,,12.46,7.48,,9.35,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.35,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.57,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.37,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.97,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.35,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.57,9.97,
DARBEPOETIN ALFA/ALUMINUM 1MCG,1402204,CDM,636,RC,J0881,HCPCS,both,,,27.32,16.39,,20.49,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,20.49,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,2.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.83,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,3.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.83,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.32,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.84,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,3,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,21.86,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3.81,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.95,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2.95,21.86,
DEFEROXAMINE 500MG INJ,1402675,CDM,636,RC,J0895,HCPCS,both,,,112.99,67.79,,84.74,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,84.74,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.62,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.42,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,9.63,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,90.39,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,71.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.55,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.55,90.39,
DEPO-TESTADIOL INJ 1ML,1401565,CDM,636,RC,,,both,,,117.47,70.48,,88.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,88.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,74.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.07,93.98,
DESMOPRESSIN INJ 4MCG/ML,1402499,CDM,636,RC,J2597,HCPCS,both,,,110.36,66.22,,82.77,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,82.77,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.99,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.51,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,23.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,6.27,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,88.29,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,69.53,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.15,88.29,
DEXMEDETOMIDINE (PRECEDEX) 100MCG/ML 2ML,1404642,CDM,636,RC,J2704,HCPCS,both,,,166.91,100.15,,125.18,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,125.18,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,35.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.53,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,133.53,
DEXMEDETOMIDINE (PRECEDEX) 4MCG/ML 100ML,1404641,CDM,636,RC,J2704,HCPCS,both,,,335.46,201.28,,251.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,251.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,72.12,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,268.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,211.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,268.37,
DEXMEDETOMIDINE (PRECEDEX) 4MCG/ML 100ML,1404655,CDM,636,RC,J2704,HCPCS,both,,,197.25,118.35,,147.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,147.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,42.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,157.8,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,147.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,124.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,157.8,
DEXTRAN 40/D5W 500ML,1402190,CDM,636,RC,J7100,HCPCS,both,,,91.77,55.06,,68.83,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,68.83,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.33,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,19.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.42,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,68.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,57.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.8,73.42,
DIAZEPAM (VALIUM) 5MG/ML 2ML INJ,1400687,CDM,636,RC,J3360,HCPCS,both,,,105.45,63.27,,79.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,79.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.16,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.99,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.36,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,66.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,84.36,
DICYCLOMINE (BENTYL) 10MG/ML INJ 2ML,1400851,CDM,636,RC,J0500,HCPCS,both,,,96.26,57.76,,72.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,72.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,31.1,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,27.22,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,31.15,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,77.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,72.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,60.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.22,77.01,
DIGIBIND,1402554,CDM,636,RC,J1162,HCPCS,both,,,3164.26,1898.56,,2373.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,2373.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4593.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5971.64,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,673.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,673.99,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4293.36,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,680.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,4685.43,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2531.41,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,2373.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2373.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2373.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2373.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4593.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,4593.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,648.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1993.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,4593.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,648.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4593.57,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,648.36,5971.64,
DIGOXIN (LANOXIN) 0.25MG/ML 2ML INJ,1400325,CDM,636,RC,J1160,HCPCS,both,,,29.28,17.57,,21.96,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,21.96,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.3,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,25,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.42,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.3,25,
DOBUTAMINE 250MG/D5W 250ML INJ,1401933,CDM,636,RC,J1250,HCPCS,both,,,83.54,50.12,,62.66,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,62.66,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.35,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.83,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,62.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,52.63,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.35,66.83,
DOBUTAMINE 500MG/250ML D5W PREMIX,1404023,CDM,636,RC,J1250,HCPCS,both,,,28.69,17.21,,21.52,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,21.52,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.35,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.95,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,18.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.35,22.95,
DOBUTAMINE INJ 250MG/20ML,1400778,CDM,636,RC,J1250,HCPCS,both,,,55.73,33.44,,41.8,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,41.8,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.35,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.58,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,35.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.35,44.58,
DOLASETRON MESYLATE INJ 12.5MG (20MG/ML),1402170,CDM,636,RC,J1260,HCPCS,both,,,131.55,78.93,,98.66,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,98.66,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,28.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.24,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,98.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,98.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,82.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,105.24,
DOPAMINE 40MG/ML 5ML INJ,1400282,CDM,636,RC,J1265,HCPCS,both,,,10.11,6.07,,7.58,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.58,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.49,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.09,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,8.09,
DOPAMINE INJ 400MG/10ML INJ,1404638,CDM,636,RC,J1265,HCPCS,both,,,21.22,12.73,,15.92,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,15.92,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.49,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.49,16.98,
DURAMORPH INJ 5MG/10ML,1402040,CDM,636,RC,J2270,HCPCS,both,,,31.69,19.01,,23.77,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,23.77,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.35,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,25.35,
E,1400164,CDM,636,RC,J1000,HCPCS,both,,,94.97,56.98,,71.23,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,71.23,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,32.14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,71.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,59.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,75.98,
ENOXAPARIN (LOVENOX) 100MG/ML INJ,1402131,CDM,636,RC,J1650,HCPCS,both,,,106,63.6,,79.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,79.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,22.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,84.8,
ENOXAPARIN (LOVENOX) 30MG/0.3ML INJ,1402016,CDM,636,RC,J1650,HCPCS,both,,,18.52,11.11,,13.89,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,13.89,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,13.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,11.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,14.82,
ENOXAPARIN (LOVENOX) 40MG/0.4ML INJ,1402198,CDM,636,RC,J1650,HCPCS,both,,,42.34,25.4,,31.76,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,31.76,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,9.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.87,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,26.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,33.87,
ENOXAPARIN (LOVENOX) 60MG INJ,5898,CDM,636,RC,J1650,HCPCS,both,,,33.68,20.21,,25.26,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,25.26,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.94,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,25.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,26.94,
ENOXAPARIN (LOVENOX) 60MG INJ,1404674,CDM,636,RC,J1650,HCPCS,both,,,33.68,20.21,,25.26,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,25.26,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.94,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,25.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,21.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,26.94,
ENOXAPARIN (LOVENOX) 80MG/0.8ML INJ,1402130,CDM,636,RC,J1650,HCPCS,both,,,39.34,23.6,,29.51,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,29.51,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.76,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.47,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,24.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,31.47,
EPINEPHRINE (ADRENALINE) 1MG/ML INJ,1400033,CDM,636,RC,J0171,HCPCS,both,,,61.75,37.05,,46.31,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,46.31,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.4,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,46.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,49.4,
EPINEPHRINE 1MG/10ML ABBJ,1400210,CDM,636,RC,J0171,HCPCS,both,,,15.85,9.51,,11.89,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,11.89,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.68,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,12.68,
EPINEPHRINE AUTO INJECTOR 0.3MG (EPIPEN),1402685,CDM,636,RC,J0171,HCPCS,both,,,460.16,276.1,,345.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,345.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.89,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,368.13,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,345.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,345.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,289.9,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,368.13,
EPOETIN ALPHA 4000 UNITS,1402716,CDM,636,RC,J0885,HCPCS,both,,,308.15,184.89,,231.11,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,231.11,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.22,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,10.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,246.52,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,231.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,194.13,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.09,246.52,
"EPOGEN INJ 10,000 UNITS/ML",1402133,CDM,636,RC,J0885,HCPCS,both,,,410.59,246.35,,307.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,307.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,10.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.22,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,10.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,7.23,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,328.47,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,307.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,307.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,258.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.09,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.09,328.47,
EPTIFIBATIDE 2MG/ML (100ML),1402717,CDM,636,RC,J1327,HCPCS,both,,,5250.28,3150.17,,3937.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3937.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1118.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1118.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.5,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1128.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4200.22,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3937.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3937.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3937.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3937.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3307.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1075.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.5,4200.22,
EPTIFIBATIDE 2MG/ML (10ML),1403995,CDM,636,RC,J1327,HCPCS,both,,,89.6,53.76,,67.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,67.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,19.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.5,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,19.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.68,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,56.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.36,71.68,
ESMOLOL (BREVIBLOC) 2500MG/250ML INJ,5213,CDM,636,RC,J1250,HCPCS,both,,,86.05,51.63,,64.54,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,64.54,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.35,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.84,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,54.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.88,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.35,68.84,
ESTRADIOL VALERATE INJ 10MG/ML,1400167,CDM,636,RC,J1380,HCPCS,both,,,150.65,90.39,,112.99,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,112.99,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.8,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,32.39,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,120.52,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.8,120.52,
ETESEVIMAB 700MG INJ,1404681,CDM,636,RC,Q0239,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
FENTANYL (SUBLIMAZE) 50MCG/ML 10ML INJ,1402696,CDM,636,RC,J3010,HCPCS,both,,,12.36,7.42,,9.27,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.27,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.89,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,9.89,
FENTANYL (SUBLIMAZE) 50MCG/ML 2ML INJ,1400596,CDM,636,RC,J3010,HCPCS,both,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,4.37,
FENTANYL (SUBLIMAZE) 50MCG/ML INJ,1404726,CDM,636,RC,J3010,HCPCS,both,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,4.37,
FENTANYL DRIP 20MCG/ML (30ML),1404052,CDM,636,RC,J3010,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.07,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,1.08,
FILGRASTIM (GRAN.COLONY STIM.FACTOR) 300,1401958,CDM,636,RC,J1442,HCPCS,both,,,1000.67,600.4,,750.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,750.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.2,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,1,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,800.54,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,750.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,750.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,630.42,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,0.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,0.99,800.54,
FLUCONAZOLE (DIFLUCAN)200MG/100ML PREMIX,1402102,CDM,636,RC,J1450,HCPCS,both,,,36.06,21.64,,27.05,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,27.05,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.88,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.85,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.72,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,28.85,
FLUCONAZOLE (DIFLUCAN)400MG/200ML PREMIX,1402103,CDM,636,RC,J1450,HCPCS,both,,,18.58,11.15,,13.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,13.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.88,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.86,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.88,14.86,
FLUPHENAZINE (PROLIXIN) 25MG/ML 5ML INJ,1401627,CDM,636,RC,J2680,HCPCS,both,,,53,31.8,,39.75,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,39.75,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,12.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.4,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,33.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,42.4,
FLUTICASONE (FLONASE) 50MCG/SPR 0.05% NS,1402058,CDM,636,RC,J3490,HCPCS,both,,,10.38,6.23,,7.79,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.79,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,6.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,8.3,
FOLIC ACID 1MG/NS 50ML,5454,CDM,636,RC,J0715,HCPCS,both,,,3.28,1.97,,2.46,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,2.46,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.71,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,2.62,
FULVESTRANT INJ. 50MG/ML,1402230,CDM,636,RC,J9395,HCPCS,both,,,749.26,449.56,,561.95,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,561.95,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,8.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,10.86,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,13.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.4,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.02,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.43,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,8.52,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,599.41,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,561.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,472.03,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,8.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.36,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,8.36,599.41,
FUROSEMIDE (LASIX) 10MG/ML 10ML INJ,1400331,CDM,636,RC,J1940,HCPCS,both,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.6,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,10.06,
FUROSEMIDE (LASIX) 10MG/ML 2ML INJ,1400330,CDM,636,RC,J1940,HCPCS,both,,,11.74,7.04,,8.81,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,8.81,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.6,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.39,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,9.39,
FUROSEMIDE (LASIX) 10MG/ML 4ML INJ,1401608,CDM,636,RC,J1940,HCPCS,both,,,11.47,6.88,,8.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,8.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.6,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.18,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,9.18,
FUROSEMIDE:100MG/NS 100ML IVPB,1402817,CDM,636,RC,J1940,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.6,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.77,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.76,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.6,0.77,
GENTAMICIN (GARAMYCIN) 10MG/ML 2ML INJ,1400236,CDM,636,RC,J1580,HCPCS,both,,,16.12,9.67,,12.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.9,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,12.9,
GENTAMICIN (GARAMYCIN) 110MG/100ML NS PB,1442824,CDM,636,RC,J1580,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,3.23,
GENTAMICIN (GARAMYCIN) 130MG/100ML NS PB,1403963,CDM,636,RC,J1580,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,3.23,
GENTAMICIN (GARAMYCIN) 40MG/ML 2ML INJ,1400237,CDM,636,RC,J1580,HCPCS,both,,,17.48,10.49,,13.11,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,13.11,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,13.98,
GENTAMICIN (GARAMYCIN) 80MG/50ML PREMIX,1401867,CDM,636,RC,J1580,HCPCS,both,,,10.38,6.23,,7.79,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.79,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,8.3,
GENTAMICIN (GARAMYCIN) 80MG/ML 2ML INJ,6158,CDM,636,RC,J1580,HCPCS,both,,,17.48,10.49,,13.11,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,13.11,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,11.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,13.98,
GENTAMICIN (GARAMYCIN): 60MG/ 50ML IVPB,1401866,CDM,636,RC,J1580,HCPCS,both,,,24.85,14.91,,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.88,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,19.88,
GENTAMICIN (GARAMYCIN)100MG/100ML PREMIX,1401868,CDM,636,RC,J1580,HCPCS,both,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,11.27,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,12.02,
GENTAMICIN (GARAMYCIN)120MG/100ML PREMIX,1402677,CDM,636,RC,J1580,HCPCS,both,,,14.76,8.86,,11.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,11.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.81,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,11.81,
GENTAMICIN (GARAMYCIN)40MG/50ML NS IVPB,1402781,CDM,636,RC,J1580,HCPCS,both,,,24.85,14.91,,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.88,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,19.88,
GLARGINE (LANTUS) 100UNITS/ML INSULIN,1402173,CDM,636,RC,J1815,HCPCS,both,,,1.09,0.65,,0.82,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.82,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,0.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,0.87,
GLUCAGON (GLUCAGEN) 1MG INJ,1400249,CDM,636,RC,J1610,HCPCS,both,,,388.2,232.92,,291.15,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,291.15,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,243.75,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,206.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,206.61,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,171.6,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,206.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,191.25,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,310.56,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,291.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,291.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,244.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,187.5,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,171.6,310.56,
GRAFTJACKET PER SQ CM,2110725,CDM,636,RC,Q4107,HCPCS,both,,,167.2,100.32,,125.4,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,125.4,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.76,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.26,133.76,
GRAFTJACKET PER SQ CM,2110887,CDM,636,RC,Q4107,HCPCS,both,,,279.46,167.68,,209.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,209.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.52,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,223.57,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,209.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,176.06,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.26,223.57,
HALOPERIDOL (HALDOL) 5MG/ML INJ,1400972,CDM,636,RC,J1630,HCPCS,both,,,24.85,14.91,,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.73,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.88,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.95,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.73,19.88,
HALOPERIDOL DEC (HALDOL DEC)100MG/ML INJ,1401770,CDM,636,RC,J1631,HCPCS,both,,,198.6,119.16,,148.95,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,148.95,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.44,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,9.45,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,158.88,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,148.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,125.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.37,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.75,158.88,
HEPARIN 25000 UNITS/1/2NS 250ML PREMIX,1404028,CDM,636,RC,J1644,HCPCS,both,,,19.94,11.96,,14.96,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,14.96,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.95,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.96,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,15.95,
HEPARIN 25000 UNITS/D5W 250ML PREMIX,1404731,CDM,636,RC,J1644,HCPCS,both,,,25.75,15.45,,19.31,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,19.31,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.6,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,20.6,
HEPARIN 5000 UNITS/ML,1400256,CDM,636,RC,J1644,HCPCS,both,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.33,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.69,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,5.69,
Hepatitis B vaccine,1401758,CDM,636,RC,90746,HCPCS,both,,,242.59,145.55,,181.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,181.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,85.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,85.37,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,70.38,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,85.51,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.07,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,152.83,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.38,194.07,
HEPATITIS-B (ENGERIX)10MCG/0.5ML PED VAC,1401902,CDM,636,RC,90744,HCPCS,both,,,102.71,61.63,,77.03,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,77.03,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.04,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,22.08,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.17,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,64.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.05,82.17,
HEPATITIS-B IMMUNE GLOBULIN (HUMAN),1401759,CDM,636,RC,J1571,HCPCS,both,,,590.62,354.37,,442.97,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,442.97,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,62.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,80.8,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,125.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.8,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,75.14,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,126.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,63.4,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,472.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,442.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,442.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,121.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,372.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,62.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,121.02,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,62.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.16,472.5,
HUMULIN-R (INSULIN) 100UNITS/ML,1401362,CDM,636,RC,J1815,HCPCS,both,,,1.09,0.65,,0.82,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.82,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,0.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,0.87,
HYDRALAZINE (APRESOLINE) 20MG/ML INJ,1400082,CDM,636,RC,J0360,HCPCS,both,,,54.85,32.91,,41.14,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,41.14,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.07,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.42,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,43.88,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,41.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,34.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.42,43.88,
HYDROCORTISONE (SOLU-CORTEF) 100MG INJ,1400574,CDM,636,RC,J1720,HCPCS,both,,,60.66,36.4,,45.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,45.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.57,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,21.71,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.53,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,38.22,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.57,48.53,
HYDROCORTISONE (SOLU-CORTEF) 250MG INJ,1400575,CDM,636,RC,J1720,HCPCS,both,,,22.13,13.28,,16.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,16.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.57,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,21.71,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.7,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.94,21.71,
HYDROCORTISONE (SOLU-CORTEF) 500MG INJ,1400576,CDM,636,RC,J1720,HCPCS,both,,,223.74,134.24,,167.81,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,167.81,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,21.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,17.57,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,21.71,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.99,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,167.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,140.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.57,178.99,
HYDROMORPHONE (DILAUDID) 2MG/ML 1ML INJ,1400183,CDM,636,RC,J1170,HCPCS,both,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.29,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.75,4.22,
HYDROMORPHONE-HP INJ 10MG/ML 1ML,1401911,CDM,636,RC,J1170,HCPCS,both,,,20.16,12.1,,15.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,15.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.21,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.29,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.13,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.18,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.29,16.13,
HYDROXYZINE HCL (VISTARIL) 50MG/ML INJ,1402806,CDM,636,RC,J3410,HCPCS,both,,,86.88,52.13,,65.16,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,65.16,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,69.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,54.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.78,69.5,
IBUPROFEN (CALDOLOR) 800MG/200ML PREMIX,1404633,CDM,636,RC,J0131,HCPCS,both,,,81.41,48.85,,61.06,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,61.06,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.2,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,17.5,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.13,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,51.29,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,65.13,
IMIPENEM-CILASTATIN SOD.:250MG INJ,1402746,CDM,636,RC,J0743,HCPCS,both,,,73.21,43.93,,54.91,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,54.91,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.28,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,9.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,58.57,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,46.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,58.57,
IMIPENEM/CILASTATIN(PRIMAXIN)500MG VIAL,1401812,CDM,636,RC,J0743,HCPCS,both,,,102.99,61.79,,77.24,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,77.24,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.28,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,9.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.39,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,77.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,64.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,82.39,
IMMUNE GLOBULIN,1401975,CDM,636,RC,J1566,HCPCS,both,,,180.02,108.01,,135.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,135.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,76.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,99.54,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,89.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,89.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,73.18,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,89.91,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,78.09,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,144.02,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,135.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,76.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,113.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,76.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,76.56,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,73.18,144.02,
A biologic medication,1402553,CDM,636,RC,J1745,HCPCS,both,,,204.06,122.44,,153.05,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,153.05,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.43,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,42.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.48,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,42.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,33.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,163.25,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,153.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,128.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.2,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,32.64,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,32.64,163.25,
INFLUENZA VIRUS VACCINE INJ.,1401880,CDM,636,RC,90630,HCPCS,both,,,97.6,58.56,,73.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,73.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,20.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,20.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.08,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,73.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,73.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,61.49,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,78.08,
INSULIN (HUMULIN R)100UN/100ML DRIP,1404694,CDM,636,RC,,,both,,,106.09,63.65,,79.57,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,79.57,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,84.87,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,79.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.74,84.87,
INSULIN DRIP (HUMULIN R)1 UNIT/ML 100ML,1402831,CDM,636,RC,J1815,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,0.6,
IRON DEXTRAN (INFED) 50MG/ML 2ML INJ,1401847,CDM,636,RC,J1750,HCPCS,both,,,114.68,68.81,,86.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,86.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,20.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,91.74,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,86.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,72.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.37,91.74,
IRON SUCROSE (VENOFER) 100MG/5ML,1404709,CDM,636,RC,J1756,HCPCS,both,,,114.68,68.81,,86.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,86.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.24,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.2,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.24,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.74,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,86.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,72.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.2,91.74,
IRON SUCROSE (VENOFER) 200MG/NS 100ML,1404710,CDM,636,RC,J1750,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.63,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.05,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,20.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,17.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.37,22.63,
KEPPRA: IVPB 500MG/100ML NS,1404025,CDM,636,RC,J1953,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,0.09,
KETOROLAC (TORADOL) 30MG/ML 2ML INJ,1401633,CDM,636,RC,J1885,HCPCS,both,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,20.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.65,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.42,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,21.42,
KETOROLAC (TORADOL) 30MG/ML INJ,1401634,CDM,636,RC,J1885,HCPCS,both,,,26.78,16.07,,20.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,20.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.78,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.65,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.42,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,16.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.77,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,21.42,
LEVETIRACETAM (KEPPRA) 100MG/ML 5ML INJ,1404024,CDM,636,RC,J1953,HCPCS,both,,,63.93,38.36,,47.95,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,47.95,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.74,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.14,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,40.28,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,51.14,
LEVOFLOXACIN:250MG IV/D5W 50ML,1402092,CDM,636,RC,J1956,HCPCS,both,,,199.35,119.61,,149.51,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,149.51,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,42.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.48,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,149.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,149.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,125.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,159.48,
LEVOFLOXACIN(LEVAQUIN)750MG/150ML PREMIX,1402698,CDM,636,RC,J1956,HCPCS,both,,,27.04,16.22,,20.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,20.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.76,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.88,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.63,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,17.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.88,21.63,
LIDOCAINE (XYLOCAINE) 1% 10MG/ML 20ML,5210,CDM,636,RC,J3490,HCPCS,both,,,12.3,7.38,,9.23,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.23,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.62,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.64,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.84,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.52,9.84,
LIDOCAINE (XYLOCAINE) 1% 10MG/ML 50ML,1401186,CDM,636,RC,J2001,HCPCS,both,,,20.71,12.43,,15.53,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,15.53,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.57,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,15.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.05,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,16.57,
LIDOCAINE (XYLOCAINE) 1% 2ML AMP PF,1402668,CDM,636,RC,J2001,HCPCS,both,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,3.5,
LIDOCAINE (XYLOCAINE) 2% 2ML PF,1404658,CDM,636,RC,J2001,HCPCS,both,,,9.84,5.9,,7.38,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.38,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,7.87,
LIDOCAINE IV INJ 1% 20ML,1403964,CDM,636,RC,J2001,HCPCS,both,,,5.39,3.23,,4.04,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.04,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.02,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.02,4.31,
LIDOCAINE-MPF(XYLOCAINE) 1% 2ML VIAL,1404005,CDM,636,RC,,,both,,,7.92,4.75,,5.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.34,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,4.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.62,6.34,
LIDOCAINE-MPF(XYLOCAINE) 1% 5ML VIAL,1404657,CDM,636,RC,,,both,,,13.93,8.36,,10.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,10.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.14,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,8.78,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,11.14,
LINEZOLID (ZYVOX) 600MG/300ML PREMIX,1404699,CDM,636,RC,J2020,HCPCS,both,,,134.21,80.53,,100.66,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,100.66,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.86,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,100.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.66,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,84.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.05,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.86,107.37,
LORAZEPAM (ATIVAN) 2MG/ML 10ML INJ,1403998,CDM,636,RC,J2060,HCPCS,both,,,53.54,32.12,,40.16,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,40.16,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.74,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,11.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,33.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,42.83,
LORAZEPAM (ATIVAN) 2MG/ML INJ,1400874,CDM,636,RC,J2060,HCPCS,both,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.93,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.74,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.94,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,3.5,
LORAZEPAM INJ 4MG/ML,1402754,CDM,636,RC,J2060,HCPCS,both,,,29.18,17.51,,21.89,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,21.89,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.74,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.34,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.74,23.34,
LR 1000ML,1400014,CDM,636,RC,J7120,HCPCS,both,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,30.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.49,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.13,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,32.13,
LR 250ML,1404743,CDM,636,RC,J7120,HCPCS,both,,,14.94,8.96,,11.21,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,11.21,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.03,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.49,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.04,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.95,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,11.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.01,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.49,11.95,
MAGNESIUM 1GM/100ML D5W PREMIX,1402838,CDM,636,RC,J3475,HCPCS,both,,,14.48,8.69,,10.86,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,10.86,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.58,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.12,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,11.58,
MAGNESIUM 2GM/50ml SW PREMIX,1404734,CDM,636,RC,J3475,HCPCS,both,,,55.41,33.25,,41.56,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,41.56,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.33,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,41.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,34.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,44.33,
MAGNESIUM 50% 5GM/10ML ABBJ,1400371,CDM,636,RC,J3475,HCPCS,both,,,67.48,40.49,,50.61,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,50.61,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,42.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,53.98,
MAGNESIUM SULFATE 50% 1GM/2ML INJ,1400372,CDM,636,RC,J3475,HCPCS,both,,,28.14,16.88,,21.11,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,21.11,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.51,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,17.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,22.51,
MAGNESIUM SULFATE DRIP 40GM/1000ML,1402201,CDM,636,RC,J3475,HCPCS,both,,,43.71,26.23,,32.78,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,32.78,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.97,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,27.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,34.97,
MAGNESIUM SULFATE INJ 50% 50ML,1402186,CDM,636,RC,J3475,HCPCS,both,,,34.22,20.53,,25.67,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,25.67,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.38,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,25.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.56,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,27.38,
MAGNESIUM SULFATE: IVPB 2000MG/100ML NS,1402833,CDM,636,RC,J3475,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,0.92,
MANNITOL 25% 250MG/ML 50ML INJ,1400018,CDM,636,RC,J2150,HCPCS,both,,,16.39,9.83,,12.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.28,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.6,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.11,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.24,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.6,13.11,
MEDROXYPROGESTERONE 150MG/ML INJ,1401906,CDM,636,RC,J1050,HCPCS,both,,,284.38,170.63,,213.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,213.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.57,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.66,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,227.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,179.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.65,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.57,227.5,
MEPERIDINE (DEMEROL) 25MG/ML 1ML INJ,1401443,CDM,636,RC,J2175,HCPCS,both,,,8.96,5.38,,6.72,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,6.72,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.11,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.28,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.17,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,6.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.72,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.64,7.28,
MEPERIDINE (DEMEROL) 50MG/ML 1ML INJ,1400163,CDM,636,RC,J2175,HCPCS,both,,,9.84,5.9,,7.38,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.38,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.11,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.28,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.87,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,7.87,
MEPERIDINE (DEMEROL) 75MG/1.5ML INJ,1401435,CDM,636,RC,J2175,HCPCS,both,,,6.37,3.82,,4.78,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.78,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.11,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.28,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.1,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.01,7.28,
MEPERIDINE INJ 10MG/ML PCA,1401858,CDM,636,RC,J2175,HCPCS,both,,,55.17,33.1,,41.38,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,41.38,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.11,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.28,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,44.14,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,34.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,44.14,
MEPERIDINE INJ 50MG/ML 30ML,1401744,CDM,636,RC,J2175,HCPCS,both,,,342.15,205.29,,256.61,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,256.61,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,7.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.11,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,7.28,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,273.72,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,256.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,256.61,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,215.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.11,273.72,
METHOCARBAMOL : 100MG/ML INJ 10ML,1400535,CDM,636,RC,J2800,HCPCS,both,,,76.22,45.73,,57.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,57.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.71,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,48.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.71,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.51,60.98,
METHOTREXATE 25MG/ML INJ 2ML,1402598,CDM,636,RC,J9260,HCPCS,both,,,31.42,18.85,,23.57,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,23.57,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.18,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.97,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.18,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.14,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.79,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.97,25.14,
METHYLENE BLUE 1% 5MG/ML 10ML,1401220,CDM,636,RC,Q9968,HCPCS,both,,,439.83,263.9,,329.87,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,329.87,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,9.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,93.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,7.63,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,351.86,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,329.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,90.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,277.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,90.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.49,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.49,351.86,
METHYLERGONOVINE (METHERGINE) 0.2MG/ML,1401848,CDM,636,RC,J2210,HCPCS,both,,,103.81,62.29,,77.86,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,77.86,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,24.75,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.2,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,24.79,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,83.05,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,65.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.2,83.05,
METHYLPRED SOD SUCC (SOLU-MEDROL) 125MG,1400583,CDM,636,RC,J2930,HCPCS,both,,,39.86,23.92,,29.9,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,29.9,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.52,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.89,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.52,31.89,
METHYLPRED SOD SUCC (SOLU-MEDROL) 40MG,1400582,CDM,636,RC,J2920,HCPCS,both,,,24.74,14.84,,18.56,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,18.56,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.19,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.79,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,19.79,
METHYLPREDNIS ACE (DEPO-MEDROL) 40MG/ML,1400165,CDM,636,RC,J1030,HCPCS,both,,,57.68,34.61,,43.26,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,43.26,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.04,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.93,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,9.05,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,46.14,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,36.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.93,46.14,
METHYLPREDNISOLONE INJ 80MG/ML(DEPO-MEDR,1402041,CDM,636,RC,J1040,HCPCS,both,,,255.42,153.25,,191.57,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,191.57,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.44,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,14.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,204.34,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,191.57,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,160.91,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.44,204.34,
METHYLPREDNISOLONE SOD 500MG INJ(S-MEDRO,1400585,CDM,636,RC,J2930,HCPCS,both,,,62.84,37.7,,47.13,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,47.13,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.96,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.52,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.27,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,47.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,39.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.52,50.27,
METHYLPREDNISOLONE SOD SUCCINATE:1000MG,1400586,CDM,636,RC,J2920,HCPCS,both,,,93.43,56.06,,70.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,70.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.19,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.2,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.74,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,58.86,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.19,74.74,
METOCLOPRAMIDE (REGLAN) 5MG/ML 2ML INJ,1400799,CDM,636,RC,J2765,HCPCS,both,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.05,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.29,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.28,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.05,3.5,
MIDAZOLAM (VERSED) 1MG/ML 2ML INJ,1401397,CDM,636,RC,J2250,HCPCS,both,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,3.5,
MIDAZOLAM (VERSED) 5MG/5ML INJ,5673,CDM,636,RC,J2250,HCPCS,both,,,10.88,6.53,,8.16,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,8.16,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.7,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,8.7,
MIDAZOLAM (VERSED) 5MG/ML 10ML INJ,1402738,CDM,636,RC,J2250,HCPCS,both,,,41.52,24.91,,31.14,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,31.14,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.22,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,26.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,33.22,
MIDAZOLAM (VERSED) 5MG/ML 1ML INJ,1401951,CDM,636,RC,J2250,HCPCS,both,,,72.12,43.27,,54.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,54.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.22,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.22,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.7,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,45.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.22,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,57.7,
MILRINONE LACTATE INJ 0.2MG/ML,1402017,CDM,636,RC,J2260,HCPCS,both,,,797.42,478.45,,598.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,598.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.17,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.71,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,637.94,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,598.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,598.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,598.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,598.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,502.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.71,637.94,
MORPHINE (DURAMORPH) 0.5MG/ML 10ML INJ,1402750,CDM,636,RC,J2270,HCPCS,both,,,16.12,9.67,,12.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.09,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.9,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.09,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,12.9,
MORPHINE 2MG/ML 1ML INJ,1403957,CDM,636,RC,J2270,HCPCS,both,,,10.38,6.23,,7.79,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,7.79,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.3,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.54,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,8.3,
MORPHINE 4MG/ML 1ML INJ,1401360,CDM,636,RC,J2270,HCPCS,both,,,7.37,4.42,,5.53,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.53,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.9,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.64,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,5.9,
MORPHINE INJ 1MG/ML 30ML PCA,1401888,CDM,636,RC,J2270,HCPCS,both,,,41.25,24.75,,30.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,30.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,25.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,33,
MORPHINE SO4 10MG/ML 10ML,1401748,CDM,636,RC,J2270,HCPCS,both,,,210.33,126.2,,157.75,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,157.75,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,168.26,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,157.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,157.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,132.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,168.26,
MORPHINE SULFATE INJ 15MG,1400387,CDM,636,RC,J2270,HCPCS,both,,,77.71,46.63,,58.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,58.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.17,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,48.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,62.17,
MORPHINE SULFATE INJ 5MG,1402705,CDM,636,RC,J2270,HCPCS,both,,,5.3,3.18,,3.98,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.98,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.61,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.24,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.34,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.58,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.34,5.13,
NALBUPHINE INJ 10MG/ML,1400845,CDM,636,RC,J2300,HCPCS,both,,,7.16,4.3,,5.37,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.37,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.82,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.73,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,5.73,
NALBUPHINE INJ 20MG/ML,1402628,CDM,636,RC,J2300,HCPCS,both,,,33.95,20.37,,25.46,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,25.46,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.81,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.82,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.16,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.78,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,27.16,
NALOXONE (NARCAN) 0.4MG/ML INJ,1404664,CDM,636,RC,J2310,HCPCS,both,,,22.28,13.37,,16.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,16.71,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.59,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,12.13,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,16.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,14.04,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,17.82,
NALOXONE (NARCAN) 1MG/ML 2ML INJ,1402699,CDM,636,RC,J2310,HCPCS,both,,,243.14,145.88,,182.36,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,182.36,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.59,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,12.13,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,194.51,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,182.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,182.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,153.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.59,194.51,
NEOSTIGMINE 1MG/ML 10ML INJ,1400519,CDM,636,RC,J2710,HCPCS,both,,,37.15,22.29,,27.86,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,27.86,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.97,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.97,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.72,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,23.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,29.72,
NF-FLUOROURACIL:500MG INJ,1402458,CDM,636,RC,J9190,HCPCS,both,,,21.03,12.62,,15.77,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,15.77,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.86,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.13,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.87,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,13.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.13,16.82,
NF-GENTAMICIN:40MG INJ (20ML VIAL),1401214,CDM,636,RC,J1580,HCPCS,both,,,4.1,2.46,,3.08,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.08,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.28,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,3.28,
NF-HYDROXYZINE INJ 100MG,1400713,CDM,636,RC,J3410,HCPCS,both,,,7.96,4.78,,5.97,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.97,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.97,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.01,13.78,
NF-HYDROXYZINE INJ 25MG,1402707,CDM,636,RC,J3410,HCPCS,both,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.76,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.78,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.66,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.44,13.78,
NF-LEUCOVORIN:50MG INJ,1402459,CDM,636,RC,J0640,HCPCS,both,,,93.98,56.39,,70.49,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,70.49,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,75.18,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,59.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.84,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,75.18,
NF-POTASSIUM CHLORIDE LIQ 40MEQ/30ML UD,1403960,CDM,636,RC,J3480,HCPCS,both,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.31,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,4.59,
NF-RANITIDINE (ZANTAC) 25MG/ML INJ 6ML,1401815,CDM,636,RC,J2780,HCPCS,both,,,52.18,31.31,,39.14,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,39.14,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,11.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.74,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,32.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,41.74,
NICARDIPINE 20MG/200ML NS PREMIX,1404736,CDM,636,RC,J3475,HCPCS,both,,,298.7,179.22,,224.03,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,224.03,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,238.96,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,224.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,224.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,188.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,238.96,
NOVOLIN (INSULIN) 70/30 100U/ML,1401367,CDM,636,RC,J1815,HCPCS,both,,,1.09,0.65,,0.82,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.82,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,0.69,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,0.87,
NPH U-100 HUMULIN INSULIN (EMP. ONLY),1401833,CDM,636,RC,J1815,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.59,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.53,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.6,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.59,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.53,0.6,
OLANZAPINE (ZYPREXA) 10MG INJ,1402465,CDM,636,RC,J2358,HCPCS,both,,,139.6,83.76,,104.7,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,104.7,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.91,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,30.01,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,111.68,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,87.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.91,111.68,
ONDANSETRON (ZOFRAN) 2MG/ML 2ML INJ,1401963,CDM,636,RC,J2405,HCPCS,both,,,4.37,2.62,,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.11,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.11,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.5,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,2.75,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.11,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.09,3.5,
OPRELVEKIN INJ 5MG,1402124,CDM,636,RC,J2355,HCPCS,both,,,881.08,528.65,,660.81,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,660.81,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,187.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,187.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,189.43,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704.86,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,660.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,660.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,555.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,704.86,
ORPHENADRINE (NORFLEX) 60MG/2ML INJ,1400452,CDM,636,RC,J2360,HCPCS,both,,,108.46,65.08,,81.35,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,81.35,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,86.77,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,81.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.9,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,68.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.9,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.12,86.77,
OXACILLIN 2GM VIAL,1404738,CDM,636,RC,J0290,HCPCS,both,,,34.51,20.71,,25.88,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,25.88,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.61,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,21.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,27.61,
OXACILLIN 2GM/NS 100ML IVPB,1404739,CDM,636,RC,J0290,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.75,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.75,0.92,
OXYTOCIN (PITOCIN) 10 UNITS/ML INJ,1400502,CDM,636,RC,J2590,HCPCS,both,,,12.58,7.55,,9.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.06,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7.93,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,10.06,
OXYTOCIN INJ 10 UNITS/ML (10ML VIAL),1403852,CDM,636,RC,J2590,HCPCS,both,,,30.32,18.19,,22.74,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,22.74,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.87,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.26,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,19.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.21,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.87,24.26,
PAMIDRONATE (AREDIA) 9MG/ML 10ML INJ,1402084,CDM,636,RC,J2430,HCPCS,both,,,381.91,229.15,,286.43,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,286.43,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.58,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.53,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,286.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,240.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.58,305.53,
PANTOPRAZOLE (PROTONIX) 40MG INJ,1402154,CDM,636,RC,C9113,HCPCS,both,,,20.22,12.13,,15.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,15.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.18,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,12.74,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.14,16.18,
PAPAVERINE 60MG/2ML INJ,1404000,CDM,636,RC,J2440,HCPCS,both,,,29.44,17.66,,22.08,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,22.08,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,6.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.5,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.55,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,22.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.08,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,6.03,37.5,
PAPAVERINE INJ 30MG/ML,1401971,CDM,636,RC,J2440,HCPCS,both,,,37.67,22.6,,28.25,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,28.25,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.02,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.5,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.14,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,23.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.72,37.5,
PEGFILGRASTIM 6MG/0.6ML,1402552,CDM,636,RC,J2505,HCPCS,both,,,12403.82,7442.29,,9302.87,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9302.87,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2642.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2642.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3733.77,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2666.82,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9923.06,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9302.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9302.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9302.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9302.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2541.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7814.41,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2541.54,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2541.54,9923.06,
PEN.-PROCAINE 1.2 MILLION UNITS.,1401586,CDM,636,RC,J0558,HCPCS,both,,,129.7,77.82,,97.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,97.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,15.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.46,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,15.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,12.86,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,16.05,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,103.76,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,97.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,81.71,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,15.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,15.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.86,103.76,
PENICILLIN G B/P (BICILLIN CR)1.2 MU/2ML,1401533,CDM,636,RC,J2510,HCPCS,both,,,282.8,169.68,,212.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,212.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,40.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,53.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,42.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.82,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,35.23,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,42.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,41.75,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.24,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,212.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,212.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,40.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,40.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,178.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,40.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,42.53,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,40.94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,35.23,226.24,
PENICILLIN G BENZ (BICILLIN LA)1.2MU/2ML,1400086,CDM,636,RC,J0561,HCPCS,both,,,127.31,76.39,,95.48,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,95.48,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.48,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,20.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,101.85,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,80.21,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.48,101.85,
PENICILLIN G BENZATHINE INJ 1.2 MIL.UNIT,1401375,CDM,636,RC,J0561,HCPCS,both,,,278.49,167.09,,208.87,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,208.87,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,20.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,20.29,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,16.48,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,20.33,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,20.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,222.79,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,208.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,175.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,20.16,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,20.16,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,16.48,222.79,
"PENICILLIN G POT:1,000,000 UNITS INJ",1400473,CDM,636,RC,J2540,HCPCS,both,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.95,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.95,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.69,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.46,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.69,5.46,
PENTAZOCINE INJ 30MG,1400618,CDM,636,RC,J3070,HCPCS,both,,,173.72,104.23,,130.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,130.29,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,37.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,130.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.29,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,109.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,138.98,
PERSANTINE 50 MG,1402686,CDM,636,RC,J1245,HCPCS,both,,,95.07,57.04,,71.3,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,71.3,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.5,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.06,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,59.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.51,76.06,
PHENOBARBITAL 65MG/ML INJ,1401619,CDM,636,RC,J2560,HCPCS,both,,,89.06,53.44,,66.8,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,66.8,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,47.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,54.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,54.5,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,40.3,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,54.59,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,36.97,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,71.25,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,56.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,54.14,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,36.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.25,71.25,
PHENYLEPHRINE (NEOSYNEPHRINE) 10MG/ML VL,1401226,CDM,636,RC,J2370,HCPCS,both,,,15.02,9.01,,11.27,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,11.27,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.2,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.02,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,9.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,12.02,
PHENYLEPHRINE 100MCG/ML INJ 10ML,1404730,CDM,636,RC,J2370,HCPCS,both,,,20.6,12.36,,15.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,15.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.88,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.2,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.89,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.48,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.86,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.2,16.48,
PHENYTOIN (DILANTIN) 100MG/2ML INJ,1404644,CDM,636,RC,J1165,HCPCS,both,,,5.46,3.28,,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.44,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.37,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,4.37,
PHENYTOIN (DILANTIN) 250MG/5ML INJ,1401212,CDM,636,RC,J1165,HCPCS,both,,,9.23,5.54,,6.92,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,6.92,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.55,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.44,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.55,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.38,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,5.81,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.44,7.38,
PHYTONADIONE (VITAMIN K) 10MG/ML INJ,1400085,CDM,636,RC,J3430,HCPCS,both,,,192.87,115.72,,144.65,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,144.65,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.22,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,154.3,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,121.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,154.3,
PHYTONADIONE (VITAMIN K) 1MG/0.5ML INJ,1401522,CDM,636,RC,J3430,HCPCS,both,,,16.67,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,4.02,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.22,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.02,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.34,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.99,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.22,13.34,
pneumococcal Pneumococcal vaccine,1402658,CDM,636,RC,90732,HCPCS,both,,,432.72,259.63,,324.54,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,324.54,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,161.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,161.9,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,133.47,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,162.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,346.18,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,324.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,324.54,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,272.61,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.82,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,133.47,346.18,
PNEUMONCOCCAL CONJ (PREVNAR13) 0.5ML VAC,1403983,CDM,636,RC,90670,HCPCS,both,,,418.51,251.11,,313.88,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,313.88,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,312.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,312.94,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,257.99,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,313.46,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,334.81,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,313.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.88,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,263.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,310.85,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,257.99,334.81,
POTASSIUM CHLORIDE (K-RIDER) 10MEQ/100ML,1404027,CDM,636,RC,J3480,HCPCS,both,,,11.67,7,,8.75,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,8.75,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.34,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,7.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,9.34,
POTASSIUM CHLORIDE (K-RIDER) 20MEQ/100ML,1402455,CDM,636,RC,J3480,HCPCS,both,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.62,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,10.26,
POTASSIUM CHLORIDE (K-RIDER) 20MEQ/50ML,1404716,CDM,636,RC,J3480,HCPCS,both,,,12.83,7.7,,9.62,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.62,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.26,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.08,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,10.26,
POTASSIUM CHLORIDE 20MEQ/15ML ORAL LIQ,1402205,CDM,636,RC,J3490,HCPCS,both,,,47.53,28.52,,35.65,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,35.65,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.02,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,29.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,38.02,
POTASSIUM CHLORIDE 2MEQ/ML 10ML INJ,1401932,CDM,636,RC,J3480,HCPCS,both,,,14.2,8.52,,10.65,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,10.65,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.36,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,11.36,
POTASSIUM CHLORIDE: 10MEQ INJ.,1401927,CDM,636,RC,J3480,HCPCS,both,,,4.78,2.87,,3.59,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.59,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,3.82,
POTASSIUM CHLORIDE: 40MEQ INJ.,1401232,CDM,636,RC,J3480,HCPCS,both,,,5.57,3.34,,4.18,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.18,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.19,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.19,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.46,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.51,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.19,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.17,4.46,
PREDNISONE ORAL SOLN 5MG/5ML,1401658,CDM,636,RC,J7512,HCPCS,both,,,5.74,3.44,,4.31,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,4.31,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.22,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,3.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,4.59,
PRIMAXIN: 250MG/NS 100ML IVPB,1402792,CDM,636,RC,J0743,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.28,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,9.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,9.95,
PRIMAXIN: 500MG/NS 100ML IVPB,1402791,CDM,636,RC,J0743,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,9.93,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.28,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,9.95,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.28,9.95,
PROCAINAMIDE INJ 1000MG/10ML,1401452,CDM,636,RC,J2690,HCPCS,both,,,126.48,75.89,,94.86,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,94.86,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,124.27,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,113.93,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,124.48,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.18,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,94.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,79.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.44,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.68,124.48,
PROGESTERONE INJ 50MG/ML,1401233,CDM,636,RC,J2675,HCPCS,both,,,66.65,39.99,,49.99,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,49.99,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.26,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.26,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.32,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.99,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,41.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.25,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.09,53.32,
PROMETHAZINE (PHENERGAN) 25MG/ML INJ,1400496,CDM,636,RC,J2550,HCPCS,both,,,6.83,4.1,,5.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.46,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,5.46,
PROMETHAZINE (PHENERGAN) 50MG/ML INJ,1403849,CDM,636,RC,J2550,HCPCS,both,,,4.92,2.95,,3.69,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.69,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.57,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.78,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.57,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.54,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.78,3.94,
PROPOFOL (DIPRIVAN) 10MG/ML 100ML INJ,1401934,CDM,636,RC,J2704,HCPCS,both,,,123.75,74.25,,92.81,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,92.81,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,26.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,92.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,77.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,99,
PROPOFOL (DIPRIVAN) 10MG/ML 20ML INJ,1401844,CDM,636,RC,J2704,HCPCS,both,,,24.85,14.91,,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,18.64,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,5.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,19.88,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,15.66,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,19.88,
PROPOFOL (DIPRIVAN)10MG/ML 50ML VIAL,1464626,CDM,636,RC,J2704,HCPCS,both,,,57.07,34.24,,42.8,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,42.8,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,12.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,45.66,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,35.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.69,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.12,45.66,
PROTAMINE SULFATE 10MG/ML 25ML INJ,1400915,CDM,636,RC,J2720,HCPCS,both,,,151.83,91.1,,113.87,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,113.87,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.81,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.46,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,113.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,113.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,95.65,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.81,121.46,
RABIES IMMUNE GLOBULIN (HUMAN) 2ML,1402128,CDM,636,RC,90375,HCPCS,both,,,817.36,490.42,,613.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,613.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,361.06,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,258.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,258.66,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,286.02,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,259.09,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,283.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,653.89,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,613.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,613.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,256.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,514.94,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,256.93,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,277.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,256.93,653.89,
RABIES VACCINE 1ML,1402129,CDM,636,RC,90675,HCPCS,both,,,863.25,517.95,,647.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,647.44,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,427.11,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,422.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,422.77,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,291.79,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,423.46,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,335.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,690.6,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,647.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,647.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,419.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,543.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,419.94,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,328.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,291.79,690.6,
RANITIDINE:25MG/ML INJ (2ML AMP.),1400848,CDM,636,RC,J2780,HCPCS,both,,,21.54,12.92,,16.16,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,16.16,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,4.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,4.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.23,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,16.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,13.57,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,17.23,
REGADENOSON (LEXISCAN) 0.4MG/5ML INJ,1402752,CDM,636,RC,J2785,HCPCS,both,,,629.98,377.99,,472.49,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,472.49,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,74.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,74.42,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,61.48,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,74.54,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,503.98,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,472.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,472.49,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,396.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,73.92,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.48,503.98,
REGEN-COV(CASIRIVIMAB/IMDEVIMAB) 600/600,1404691,CDM,636,RC,Q0243,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,0.01,
REMDESIVIR (VEKLURY) 100MG INJ,1404646,CDM,636,RC,J0248,HCPCS,both,,,1136.44,681.86,,852.33,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,852.33,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.69,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,909.15,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,852.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,852.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,852.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,852.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,715.96,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.51,909.15,
REMDESIVIR 100MG/NS 250ML,1404648,CDM,636,RC,J0248,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.69,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.51,7.87,
REMDESIVIR 200MG/NS 250ML,1404647,CDM,636,RC,J0248,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,7.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,6.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,6.68,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,5.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,6.69,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,6.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,6.64,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,6.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,5.51,7.87,
RETACRIT (EPOETIN) 40000UNITS/ML,1404692,CDM,636,RC,Q5105,HCPCS,both,,,584.56,350.74,,438.42,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,438.42,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,0.84,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,0.98,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,467.65,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,438.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,438.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,368.27,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.98,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.84,467.65,
RETEPLASE RECOMBINANT IV(18.1MG),1402105,CDM,636,RC,J2993,HCPCS,both,,,11514.89,6908.93,,8636.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,8636.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,2787.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3624.38,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,2452.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2452.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2740.17,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2475.7,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2843.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,9211.91,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,8636.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8636.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8636.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8636.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2787.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2787.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2359.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7254.38,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,2787.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2359.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2787.99,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2359.4,9211.91,
RHO(D) IMMUNE GLOBULIN 300MCG/2ML,1402798,CDM,636,RC,J2790,HCPCS,both,,,425.96,255.58,,319.47,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,319.47,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,97.54,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,97.54,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,79.47,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,97.7,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,340.77,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,319.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,319.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,268.35,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.47,340.77,
RISPERIDONE (RISPERDAL) CONSTA 12.5MG,1402570,CDM,636,RC,J2794,HCPCS,both,,,373.71,224.23,,280.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,280.28,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.47,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,14.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,298.97,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,280.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,235.44,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.47,298.97,
RISPERIDONE (RISPERDAL) CONSTA 25mg INJ,1404084,CDM,636,RC,J2794,HCPCS,both,,,812.18,487.31,,609.14,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,609.14,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,15.79,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,14.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,14.06,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.47,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,14.08,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,12.39,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,649.74,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,609.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,609.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,511.67,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,13.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.47,649.74,
ROPIVACAINE (NAROPIN) 0.2%2MG/ML 10ML,1403984,CDM,636,RC,J2795,HCPCS,both,,,16.67,10,,12.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,12.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.07,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.34,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,10.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,13.34,
ROPIVACAINE 0.5% IN 100ML NS,1402836,CDM,636,RC,J2795,HCPCS,both,,,185.93,111.56,,139.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,139.45,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.07,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,39.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.74,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,139.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,139.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,117.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.07,148.74,
SARGRAMOSTIM:500MCG INJ,1402349,CDM,636,RC,J2820,HCPCS,both,,,1432.22,859.33,,1074.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,1074.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,58.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,75.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,67.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,67.25,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,55.32,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,67.36,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,59.42,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1145.78,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,1074.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1074.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1074.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1074.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,902.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,58.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.8,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,58.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,55.32,1145.78,
SINCALIDE (KINEVAC) 5MCG INJ,1402673,CDM,636,RC,J2805,HCPCS,both,,,450.76,270.46,,338.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,338.07,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.01,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.27,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,96.91,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,360.61,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,338.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,283.98,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.36,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.36,360.61,
SOTROVIMAB 500MG INJ,1404723,CDM,636,RC,M0247,HCPCS,both,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,0.01,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,515.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,404.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,0.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,0.01,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,,,,,other,Not separately reimbursable for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,0.01,515.12,
"STREPTOKINASE 250,000 IU",1402720,CDM,636,RC,J2995,HCPCS,both,,,333.56,200.14,,250.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,250.17,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,71.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,250.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266.85,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,250.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,210.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.35,266.85,
SUCCINYLCHOLINE INJ 20MG/ML,1400599,CDM,636,RC,J0330,HCPCS,both,,,76.49,45.89,,57.37,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,57.37,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,16.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,16.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,16.45,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.19,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,57.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,48.19,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.67,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.96,61.19,
SUMATRIPTAN (IMITREX) 6MG/0.5ML INJ,1401905,CDM,636,RC,J3030,HCPCS,both,,,35.51,21.31,,26.63,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,26.63,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.33,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,30.33,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,25,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,30.38,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.41,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.37,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.37,30.38,
TENECTEPLASE 50MG INJ,1402740,CDM,636,RC,J3101,HCPCS,both,,,11395.51,6837.31,,8546.63,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,8546.63,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,199.03,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,2427.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2427.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,139.48,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2450.03,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,156.16,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,9116.41,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,8546.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8546.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8546.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8546.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2334.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,7179.17,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2334.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,153.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,139.48,9116.41,
TERBUTALINE (BRETHINE) 1MG/ML INJ,1400116,CDM,636,RC,J3105,HCPCS,both,,,4.92,2.95,,3.69,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,3.69,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,15.49,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.2,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,15.52,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.94,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3.69,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,3.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.39,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.1,15.52,
TESTOSTERONE CYPIONATE INJ 200MG/ML,1404060,CDM,636,RC,J1000,HCPCS,both,,,46.99,28.19,,35.24,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,35.24,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,32.08,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,26.09,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,32.14,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,37.59,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,29.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.87,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.09,37.59,
TET IMMUNE GLOBULIN (HUMAN) 250 UNITS,1400258,CDM,636,RC,J1670,HCPCS,both,,,507.57,304.54,,380.68,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,380.68,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,584.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,759.7,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,652.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,652.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,516.49,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,653.39,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,596.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,406.06,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,380.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,584.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,584.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,647.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,319.77,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,584.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,647.96,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,584.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,319.77,759.7,
TETANUS AND DIPHTHERIA TOXOIDS INJ <7 YR,1401900,CDM,636,RC,90702,HCPCS,both,,,61.47,36.88,,46.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,46.1,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.18,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.1,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,38.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.6,63.01,
TETANUS AND DIPHTHERIA TOXOIDS INJ >7 YR,1402574,CDM,636,RC,90714,HCPCS,both,,,103.46,62.08,,77.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,77.6,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.99,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,34.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.77,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,77.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.6,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,65.18,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.99,82.77,
TETANUS TOXOID ADSORBED INJ,1402197,CDM,636,RC,90702,HCPCS,both,,,83.33,50,,62.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,62.5,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,17.75,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,17.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.66,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.5,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,52.5,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.07,66.66,
"TETANUS,DIPHTHERIA,PERTUSSIS (TDAP) VAC",1403996,CDM,636,RC,90714,HCPCS,both,,,154.08,92.45,,115.56,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,115.56,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,33.98,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,28.99,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,34.03,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,123.26,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,97.07,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.75,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.99,123.26,
THIAMINE (VITAMIN B1) 100MG/ML INJ 2ML,1400641,CDM,636,RC,J3411,HCPCS,both,,,40.98,24.59,,30.74,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,30.74,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.56,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.81,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.78,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.4,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.56,32.78,
TICE BCG,1403853,CDM,636,RC,90586,HCPCS,both,,,331.09,198.65,,248.32,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,248.32,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,172.6,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,141.65,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,172.88,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,264.87,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,248.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,248.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,208.59,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,171.45,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,141.65,264.87,
TIGECYCLINE 50MG,1402745,CDM,636,RC,J3243,HCPCS,both,,,381.64,228.98,,286.23,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,286.23,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,81.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,82.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,305.31,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,286.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,286.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,240.43,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,78.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1,305.31,
TOBRAMYCIN 80MG/2ML INJ,1402578,CDM,636,RC,J3260,HCPCS,both,,,7.11,4.27,,5.33,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,5.33,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.24,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.16,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.69,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,4.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.13,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.24,5.69,
TORSEMIDE INJ 20MG,1401984,CDM,636,RC,J3265,HCPCS,both,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,30.12,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.13,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,25.3,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,32.13,
TRIAMCINOLONE (KENALOG) 40MG/ML INJ,1400794,CDM,636,RC,J3301,HCPCS,both,,,38.24,22.94,,28.68,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,28.68,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,1.29,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,1.32,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.59,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,24.09,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.31,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.29,30.59,
TRIMETHOBENZAMIDE INJ 200MG/2ML,1400650,CDM,636,RC,J3250,HCPCS,both,,,35.8,21.48,,26.85,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,26.85,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,52.01,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,42.83,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,52.1,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.64,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,26.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.67,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,22.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.67,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.55,52.1,
VANCOMYCIN 1.25GM/NS 250ML IVPB,5190,CDM,636,RC,J3370,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,3.92,
VANCOMYCIN 1.5GM/300ML PREMIX,1404651,CDM,636,RC,J3370,HCPCS,both,,,80.32,48.19,,60.24,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,60.24,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.26,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,60.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,50.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,64.26,
VANCOMYCIN 1.5GM/NS 250ML IVPB,5212,CDM,636,RC,J3370,HCPCS,both,,,19.67,11.8,,14.75,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,14.75,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.74,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,12.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,15.74,
VANCOMYCIN 1.5GM/NS300ML IVPB,5664,CDM,636,RC,J1580,HCPCS,both,,,77.95,46.77,,58.46,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,58.46,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,62.36,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,58.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.46,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,49.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,62.36,
VANCOMYCIN 1.75GM/350ML PREMIX,1404665,CDM,636,RC,J3370,HCPCS,both,,,91.24,54.74,,68.43,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,68.43,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,72.99,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,68.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.43,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,57.48,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,72.99,
VANCOMYCIN 1.75GM/NS 500ML IVPB,5211,CDM,636,RC,J3370,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,3.92,
VANCOMYCIN 1250MG/250ML PREMIX,1404666,CDM,636,RC,J1580,HCPCS,both,,,65.25,39.15,,48.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,48.94,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.23,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.37,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.23,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,52.2,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,48.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,48.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,41.11,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.21,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.37,52.2,
VANCOMYCIN 1GM VIAL,1400689,CDM,636,RC,J3370,HCPCS,both,,,13.11,7.87,,9.83,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,9.83,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.49,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,8.26,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,10.49,
VANCOMYCIN 250/5ML ORAL SOLN,5884,CDM,636,RC,J3370,HCPCS,both,,,62.07,37.24,,46.55,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,46.55,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.66,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.55,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,39.1,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,49.66,
VANCOMYCIN 2GM/NS 500ML IVPB,5863,CDM,636,RC,J3370,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,3.92,
VANCOMYCIN 500MG VIAL,1401472,CDM,636,RC,J3370,HCPCS,both,,,31.15,18.69,,23.36,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,23.36,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.92,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.62,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,24.92,
VANCOMYCIN 500MG/NS 100ML IVPB,1402827,CDM,636,RC,J3370,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,3.92,
VANCOMYCIN 750MG/NS 250ML IVPB,1404040,CDM,636,RC,J3370,HCPCS,both,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,3.92,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,2.96,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,3.92,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3.89,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.96,3.92,
ZIDOVUDINE: 10MG/ML INJ.,1402614,CDM,636,RC,J3485,HCPCS,both,,,124.03,74.42,,93.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,93.02,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,26.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1.51,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,26.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,99.22,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.02,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,78.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1.51,99.22,
ZIPRASIDONE (GEODON) 20MG INJ,1402575,CDM,636,RC,J3486,HCPCS,both,,,30.54,18.32,,22.91,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,22.91,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.58,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.43,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,19.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.58,24.43,
ZIPRASIDONE*MES:20MG/ML INJ (10ML VIAL**,1402329,CDM,636,RC,J3486,HCPCS,both,,,492.28,295.37,,369.21,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,369.21,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,13.32,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,11.58,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,13.34,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,393.82,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,369.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,369.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,310.14,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.23,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.58,393.82,
ZOLEDRONIC ACID : INJ 4MG,1402172,CDM,636,RC,J3489,HCPCS,both,,,2616.26,1569.76,,1962.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,1962.2,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.34,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,10.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2093.01,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,1962.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1962.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1962.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1962.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,1648.24,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.34,2093.01,
ZOLENDRONIC ACID 1 MG,1402719,CDM,636,RC,J3489,HCPCS,both,,,898.22,538.93,,673.67,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,673.67,75,,,percent of total billed charges,75% of total billed charges for high cost drug carve out,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,10.15,121.3,,,fee schedule,121.3% of GA Medicaid fee schedule for outpatient setting which is 106% of the GA Medicaid rate,8.34,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,10.17,121.5,,,fee schedule,121.5% of GA Medicaid fee schedule for outpatient setting which is 107% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,718.58,80,,,percent of total billed charges,80% of total billed charges for High Cost Drug carveouts,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,673.67,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,565.88,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.09,120.49,,,fee schedule,120.49% of GA Medicaid fee schedule for outpatient setting which is 102% of the GA Medicaid rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.34,718.58,
RESPITE CARE RM/BOARD,1000005,CDM,665,RC,,,outpatient,,,201.07,120.64,,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,43.23,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,180.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,41.2,180.96,
RECOVERY ROOM,1900001,CDM,710,RC,,,outpatient,,,699.37,419.62,,524.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,559.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,148.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,524.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,150.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,629.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,524.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,524.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,440.6,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.3,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.3,629.43,
DELIVERY/RECOVERY 1ST HR,1750015,CDM,720,RC,,,outpatient,,,85.51,51.31,,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,18.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,76.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,64.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,17.52,522,
DELIVERY/RECOVERY EA ADDTL HR,1750014,CDM,720,RC,,,outpatient,,,42.89,25.73,,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,38.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.17,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.79,522,
A common prenatal test used to check on a baby's health.,1750002,CDM,720,RC,59025,HCPCS,outpatient,,,383.27,229.96,,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,306.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,203.67,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,81.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,159.81,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,344.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,287.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.53,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,156.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,78.53,522,
LABOR CHARGE PER HOUR,1750016,CDM,720,RC,,,outpatient,,,57.09,34.25,,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.7,522,
LABOR-DELIVERY ROOM,1750001,CDM,720,RC,,,outpatient,,,1528.18,916.91,,1146.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1222.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,325.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,325.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1146.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1375.36,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1146.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1146.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,313.12,1375.36,
NORMAL VAGINAL DELIVERY,1750024,CDM,720,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,522,522,
Outpatient visit of established patient not requiring a physician,1750018,CDM,720,RC,99211,HCPCS,outpatient,,,499.1,299.46,,374.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,399.28,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,106.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,106.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,374.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,107.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,449.19,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,374.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,374.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.27,522,
Outpatient visit of established patient requiring a physician,1750019,CDM,720,RC,99212,HCPCS,outpatient,,,605.92,363.55,,454.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,484.74,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,129.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,129.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,454.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,130.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,545.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,454.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,454.44,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,124.15,545.33,
"Established patient office or other outpatient visit, typically 15 minutes",1750013,CDM,720,RC,99213,HCPCS,outpatient,,,748.52,449.11,,561.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,598.82,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,159.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,159.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,561.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,160.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,673.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,561.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,561.39,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,153.37,673.67,
"Established patient office or other outpatient visit, typically 25 minutes",1750012,CDM,720,RC,99214,HCPCS,outpatient,,,1103.66,662.2,,827.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,882.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,235.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,827.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,993.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,827.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,827.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.14,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,226.14,993.29,
"Established patient office or other outpatient, visit typically 40 minutes",1750023,CDM,720,RC,99215,HCPCS,outpatient,,,1190.54,714.32,,892.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,952.43,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,253.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,253.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,892.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.97,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1071.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,892.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,892.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,243.94,1071.49,
INJECTION OF ANTIBIOTICS,1000015,CDM,721,RC,96372,HCPCS,outpatient,,,141.23,84.74,,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,127.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.94,522,
LABOR CHECK,1750010,CDM,721,RC,,,outpatient,,,454.85,272.91,,341.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,96.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.88,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,341.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,409.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,341.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,341.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,93.2,522,
SUBSCRIPTION SCHOOL NURSE,4124024,CDM,721,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,522,522,
LANCET SAFETY GREEN 02-675-160,2100352,CDM,722,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,522,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,522,522,
EKG,2593005,CDM,730,RC,93005,HCPCS,outpatient,,,361.69,217.01,,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,77.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,325.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,727,100,,,case rate,100% UHC case rate for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,727,
EKG EMERGENCY DEPT ONLY,1800010,CDM,730,RC,93005,HCPCS,outpatient,,,108.15,64.89,,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,727,100,,,case rate,100% UHC case rate for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.16,727,
EKG EMERGENCY ROOM ONLY,1800001,CDM,730,RC,93005,HCPCS,outpatient,,,361.69,217.01,,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,77.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,325.52,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,271.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,727,100,,,case rate,100% UHC case rate for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,74.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,727,
EKG ORDER THRU RESP THERAPY,1800009,CDM,730,RC,93005,HCPCS,outpatient,,,108.15,64.89,,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,86.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,23.04,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,23.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,97.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,727,100,,,case rate,100% UHC case rate for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.16,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,22.16,727,
RHYTHM STRIP,1800003,CDM,730,RC,93041,HCPCS,outpatient,,,221.82,133.09,,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,177.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,47.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,47.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,199.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,166.37,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,727,100,,,case rate,100% UHC case rate for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.45,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,45.45,727,
TELEMETRY PER HOUR,1800011,CDM,732,RC,,,outpatient,,,385.74,231.44,,289.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,308.59,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,82.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,82.16,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,289.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,82.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,347.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,289.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,289.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,579,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.04,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,79.04,579,
EEG,2200001,CDM,740,RC,95819,HCPCS,outpatient,,,578.6,347.16,,433.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,462.88,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,123.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,433.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,520.74,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,433.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,433.95,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,495,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,118.56,520.74,
HOME SLEEP STUDY,2200011,CDM,740,RC,95806,HCPCS,outpatient,,,2286.54,1371.92,,1714.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1829.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,487.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,487.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2178.04,100,,,case rate,100% Anthem case rate for outpatient setting,491.61,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2057.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1714.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1714.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1714.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1714.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,468.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1231,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,468.51,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,2178.04,
MULTI SLEEP LATENCY TESTING,2200010,CDM,740,RC,95805,HCPCS,outpatient,,,3697.51,2218.51,,2773.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2958.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,552.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,787.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,787.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2178.04,100,,,case rate,100% Anthem case rate for outpatient setting,794.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,433.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3327.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2773.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2773.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2773.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2773.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,757.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2397,100,,,case rate,100% UHC case rate for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,757.62,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,425.21,3327.76,
PSYCH BRAIN MAP,2200007,CDM,740,RC,,,outpatient,,,2464.91,1478.95,,1848.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1971.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,525.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,525.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1848.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,529.96,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2218.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1848.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1848.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1848.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1848.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,505.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,495,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,505.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,495,2218.42,
BRONCHOSCOPY,2500101,CDM,750,RC,,,outpatient,,,1672.97,1003.78,,1254.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1338.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,356.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1254.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.69,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1505.67,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1254.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1254.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1254.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1254.73,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1053.97,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.79,1505.67,
BRONCHOSCOPY DX,2500011,CDM,750,RC,31622,HCPCS,outpatient,,,2929.57,1757.74,,2197.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2343.66,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1406.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1827.87,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,624,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,624,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,629.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1434.18,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2636.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2197.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2197.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1406.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1406.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,600.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1036,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,1406.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,600.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1406.06,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,600.27,2636.61,
ENDO/COLON EA ADDITIONAL PROCEDURE,2500075,CDM,750,RC,,,outpatient,,,840.3,504.18,,630.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,672.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,178.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,178.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,630.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,756.27,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,630.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,630.23,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,529.39,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.18,756.27,
ESOPHAGEAL DILITATION,2500015,CDM,750,RC,,,outpatient,,,1673.25,1003.95,,1254.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1338.6,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,356.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,356.4,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1254.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,359.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1505.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1254.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1254.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1254.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1254.94,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1054.15,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.85,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,342.85,1505.93,
LOWER GI PROCEDURES: COLONOSCOPY,2500024,CDM,750,RC,,,outpatient,,,4039.66,2423.8,,3029.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3231.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,860.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,860.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,3029.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,868.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3635.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3029.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3029.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3029.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3029.75,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,827.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2544.99,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,827.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,827.73,3635.69,
SIGMOIDOSCOPY-FLEXIBLE,2500023,CDM,750,RC,,,outpatient,,,1081.52,648.91,,811.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,865.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,230.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,230.36,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,811.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,973.37,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,811.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,811.14,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681.36,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,221.6,973.37,
UPPER GI PROCEDURES:ENDOSCOPY,2500025,CDM,750,RC,,,outpatient,,,3903.7,2342.22,,2927.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3122.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,831.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,831.49,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2927.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,839.3,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,3513.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2927.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2927.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2927.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2927.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2459.33,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.87,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,799.87,3513.33,
UPPER GI PROCEDURES:ENDOSCOPY COMPLEX,2500073,CDM,750,RC,,,outpatient,,,2082.46,1249.48,,1561.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1665.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,443.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,443.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1561.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.73,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1874.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1561.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1561.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1561.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1561.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1311.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,426.7,1874.21,
INSERT HEPLOCK,1750022,CDM,760,RC,36000,HCPCS,outpatient,,,72.93,43.76,,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,15.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,15.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,15.68,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,45.95,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.94,65.64,
ABD DX/TX PARACENTESIS W/O IMAGING GUIDA,2500060,CDM,761,RC,49082,HCPCS,outpatient,,,1880.98,1128.59,,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1504.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,943.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,400.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,404.41,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,740.62,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1692.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1410.74,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1185.02,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,726.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,385.41,1692.88,
Removal of amniotic fluid from the uterus for diagnostic purposes,1750007,CDM,761,RC,59000,HCPCS,outpatient,,,1678.7,1007.22,,1259.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1342.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,618.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,804.38,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,357.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,357.56,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,360.92,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,631.12,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1510.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1259.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1259.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1259.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1259.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,618.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,618.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,343.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1057.58,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,618.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,343.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,618.75,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,343.97,1510.83,
BB RHOGHAM ADMINISTRATION,1501976,CDM,761,RC,96372,HCPCS,outpatient,,,438.46,263.08,,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,350.77,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,93.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,93.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.27,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,394.61,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,328.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,276.23,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,89.84,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,394.61,
BEDSIDE PROCEDURE,1000042,CDM,761,RC,,,outpatient,,,922.54,553.52,,691.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,738.03,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,196.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,196.5,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,691.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,198.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,830.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,691.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,691.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,581.2,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,189.03,830.29,
BLADDER INSTILLATION OF BCG,2810040,CDM,761,RC,51720,HCPCS,outpatient,,,782.94,469.76,,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,626.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,715.04,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,166.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,168.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,561.03,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,704.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,493.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,550.03,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.42,1459.9,
BLOOD COLL FROM IMPLANTABLE DEVISE,2500063,CDM,761,RC,36591,HCPCS,outpatient,,,144.2,86.52,,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.36,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.71,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,129.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.15,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,90.85,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.55,132.76,
BLOOD PATCH,2400018,CDM,761,RC,62273,HCPCS,outpatient,,,1761.48,1056.89,,1321.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1409.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,736.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,375.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,375.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,378.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,578.07,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1585.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1321.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1321.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1321.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1321.11,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,360.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1109.73,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,360.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,566.74,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,360.93,1585.33,
CIRCUMCISION (OUTPATIENT),1750027,CDM,761,RC,54150,HCPCS,outpatient,,,4146.9,2488.14,,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3317.52,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2120.96,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,883.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,883.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,891.58,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1664.13,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,3732.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3110.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,849.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2612.55,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,849.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1631.51,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,849.7,3732.21,
EVALUATE PORT-A-CATH PLACEMENT,1600403,CDM,761,RC,36598,HCPCS,outpatient,,,782.94,469.76,,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,626.35,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,166.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.77,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,168.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,704.65,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,493.25,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,160.42,1459.9,
FOLEY CATHETER INSERTION,1750021,CDM,761,RC,51702,HCPCS,outpatient,,,251.88,151.13,,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,54.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,1459.9,
FOLEY CATHETER INSERTION,2500089,CDM,761,RC,51702,HCPCS,outpatient,,,251.88,151.13,,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1459.9,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,54.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,158.68,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,1459.9,
INJECTION SQ OR IM,1000017,CDM,761,RC,96372,HCPCS,outpatient,,,133.59,80.15,,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,106.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.45,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,120.23,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,100.19,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,84.16,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,27.37,120.23,
INJECTION SQ OR IM,1000029,CDM,761,RC,96372,HCPCS,outpatient,,,127.72,76.63,,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.18,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.2,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.46,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,114.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.79,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,80.46,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.17,114.95,
MID LINE PICC INSERTION,2500099,CDM,761,RC,36569,HCPCS,outpatient,,,2026.73,1216.04,,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1621.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1701.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,431.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,431.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,435.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1334.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1824.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,415.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1276.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,415.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,415.28,1946.54,
MINOR OR PROCEDURES,1000013,CDM,761,RC,,,outpatient,,,482.16,289.3,,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,385.73,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,102.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,102.7,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.66,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,433.94,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,361.62,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,303.76,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.79,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,98.79,433.94,
PICC INSERTION,2500100,CDM,761,RC,36569,HCPCS,outpatient,,,2026.73,1216.04,,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1621.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1701.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,431.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,431.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1946.54,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,435.75,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,1334.85,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1824.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1520.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,415.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1276.84,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,415.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1308.68,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,415.28,1946.54,
Outpatient visit of established patient not requiring a physician,1000007,CDM,761,RC,99211,HCPCS,outpatient,,,229.69,137.81,,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,183.75,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,48.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,48.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,206.72,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,144.7,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.06,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.06,206.72,
TREATMENT ROOM/INTERMEDIATE,1000038,CDM,761,RC,,,outpatient,,,2536.5,1521.9,,1902.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2029.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,540.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,540.27,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1902.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,545.35,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2282.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1902.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1902.38,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1598,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.73,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,519.73,2282.85,
TREATMENT ROOM/SIMPLE,1000041,CDM,761,RC,,,outpatient,,,1229.87,737.92,,922.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,983.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,261.96,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,922.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1106.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,922.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,922.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,922.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,922.4,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,774.82,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,252,1106.88,
US TRANSRECTAL,1620086,CDM,761,RC,76942,HCPCS,outpatient,,,313.89,188.33,,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,251.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,282.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,235.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,313.89,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.32,313.89,
DIRECT ADM TO OBS-CCU,2500091,CDM,762,RC,G0379,HCPCS,outpatient,,,1232.32,739.39,,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,985.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,626.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,262.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,262.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,491.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1109.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,1427,
DIRECT ADM TO OBS-OB UNIT,2500092,CDM,762,RC,G0379,HCPCS,outpatient,,,1232.32,739.39,,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,985.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,626.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,262.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,262.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,491.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1109.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,1427,
DIRECT ADMIT TO OBSERVATION,1000037,CDM,762,RC,99218,HCPCS,outpatient,,,159.26,95.56,,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,34.24,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,143.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,119.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.63,1427,
ICU OBSERVATION ROOM PER HOUR,1000024,CDM,762,RC,99218,HCPCS,outpatient,,,121.54,72.92,,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,1427,
OB OBS 1ST HOUR,1750008,CDM,762,RC,99220,HCPCS,outpatient,,,241.22,144.73,,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,192.98,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,51.38,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,51.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,217.1,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,180.92,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.43,1427,
OB OBS EA ADDL HOUR,1750009,CDM,762,RC,99218,HCPCS,outpatient,,,24.04,14.42,,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,19.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,5.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,5.17,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.64,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,4.93,1427,
OBS DIRECT ADMIT NURSING ASSESSMENT,1000014,CDM,762,RC,G0379,HCPCS,outpatient,,,1232.32,739.39,,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,985.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,626.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,262.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,262.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,491.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1109.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,1427,
OBS DIRECT ADMIT WITH CP CHF OR ASTHMA,1000019,CDM,762,RC,G0379,HCPCS,outpatient,,,1232.32,739.39,,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,985.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,626.73,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,262.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,262.48,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,264.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,491.74,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,1109.09,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,924.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,482.1,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,252.5,1427,
OBSERVATION ROOM PER HOUR,1000004,CDM,762,RC,G0378,HCPCS,outpatient,,,13.39,8.03,,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.71,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2.85,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2.88,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.05,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.04,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,2.74,1427,
TELEMETRY OBSERVATION PER HOUR,1000026,CDM,762,RC,99218,HCPCS,outpatient,,,121.54,72.92,,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.23,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,26.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,109.39,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,91.16,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,1427,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.9,1427,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",1000031,CDM,769,RC,96366,HCPCS,outpatient,,,103.81,62.29,,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,93.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,65.4,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,93.43,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",1000030,CDM,769,RC,96365,HCPCS,outpatient,,,453.76,272.26,,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,96.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,408.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,285.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,408.38,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",1000034,CDM,769,RC,96374,HCPCS,outpatient,,,453.76,272.26,,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,363.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,236.2,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,96.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,96.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,185.32,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,408.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,340.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,285.87,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,181.69,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,92.98,408.38,
ADM COVID VACCINE (ASTRA ZEN) 1ST DOSE,2500109,CDM,771,RC,0021A,HCPCS,outpatient,,,36.07,21.64,,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,129,
ADM COVID VACCINE (ASTRA ZEN) 2ND DOSE,2500110,CDM,771,RC,0022A,HCPCS,outpatient,,,59.41,35.65,,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,129,
ADM COVID VACCINE (MODERNA) 1ST DOSE,2500107,CDM,771,RC,0011A,HCPCS,outpatient,,,36.07,21.64,,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,129,
ADM COVID VACCINE (MODERNA) 2ND DOSE,2500108,CDM,771,RC,0012A,HCPCS,outpatient,,,59.41,35.65,,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,129,
ADM COVID VACCINE (PFIZER) 1ST DOSE,2500105,CDM,771,RC,0001A,HCPCS,outpatient,,,36.07,21.64,,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,28.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,7.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,7.39,129,
ADM COVID VACCINE (PFIZER) 2ND DOSE,2500106,CDM,771,RC,0002A,HCPCS,outpatient,,,59.41,35.65,,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,47.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.17,129,
ADMIN OF INFLUENZA VACCINE,2500081,CDM,771,RC,G0008,HCPCS,outpatient,,,103.81,62.29,,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,93.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,129,
ADMIN OF PNEUMO VACCINE,2500082,CDM,771,RC,G0009,HCPCS,outpatient,,,103.81,62.29,,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.05,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,48.44,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.11,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,38,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,93.43,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,77.86,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,37.26,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,21.27,129,
Immunization administration by a medical assistant or nurse,2500115,CDM,771,RC,90471,HCPCS,outpatient,,,144.28,86.57,,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,115.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.73,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.02,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,129.85,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.21,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,29.56,129.85,
IV ADM BAMLANIVIMAB-ETESEVIMAB ADM/MONIT,2500102,CDM,771,RC,M0245,HCPCS,outpatient,,,1058.84,635.3,,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,847.07,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,515.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,225.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,225.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.65,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,404.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,952.96,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,794.13,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,216.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,216.96,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,129,952.96,
IV ADM REGENERON-COV,2500103,CDM,771,RC,M0243,HCPCS,outpatient,,,620.63,372.38,,465.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,515.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,132.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,465.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,404.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,558.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,465.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.17,558.57,
IV ADMIN SOTROVIMAB,1502476,CDM,771,RC,M0247,HCPCS,outpatient,,,621.09,372.65,,465.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,496.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,515.12,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,132.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.29,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,465.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,404.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,558.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,465.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,465.82,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.26,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,396.25,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.26,558.98,
REGEN-COV 600MG/600MG/NS 50ML,1404690,CDM,771,RC,Q0243,HCPCS,outpatient,,,0.01,0.01,,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,0.01,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,0.01,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,129,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,0.01,129,
Immunization administration by a medical assistant or nurse,2500050,CDM,771,RC,90471,HCPCS,outpatient,,,141.11,84.67,,105.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,112.89,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,77.14,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,30.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,105.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.34,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,60.53,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,127,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,105.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,129,100,,,case rate,100% UHC case rate for outpatient setting,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.91,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,59.34,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,28.91,129,
Surgical procedures on the kidney to break up and remove kidney stones,1700004,CDM,790,RC,50590,HCPCS,outpatient,,,10079.31,6047.59,,7559.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8063.45,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,2819.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,3664.9,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,2146.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2146.89,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2270.12,100,,,fee schedule,100% Anthem fee schedule for outpatient setting,2167.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,2875.54,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,9071.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,7559.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7559.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7559.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,7559.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2819.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2819.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2065.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2725,100,,,fee schedule,100% UHC ASC fee schedule for outpatient setting,2819.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2065.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2819.15,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,2065.25,9071.38,
DIALYSIS,1500248,CDM,801,RC,,,outpatient,,,783.26,469.96,,587.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,626.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,166.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,166.83,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,587.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,168.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,704.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,587.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,587.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,493.45,63,,,percent of total billed charges,63% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,160.49,704.93,
"Psychotherapy, 45 min",2700002,CDM,914,RC,90834,HCPCS,outpatient,,,317.7,190.62,,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,67.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,285.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.1,285.93,
INDIVIDUAL RECREATIONAL THERAPY/1HR,2700006,CDM,914,RC,,,outpatient,,,127.03,76.22,,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,114.33,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,95.27,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.03,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,26.03,114.33,
Group psychotherapy,2700001,CDM,915,RC,90853,HCPCS,outpatient,,,176.75,106.05,,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,141.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,66.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,86.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,37.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,37.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,68.04,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,159.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.56,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,66.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,66.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,66.7,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.22,159.08,
GROUP RECREATIONAL THERAPY/1HR,2700005,CDM,915,RC,,,outpatient,,,47.53,28.52,,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,10.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,10.12,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,10.22,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,42.78,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.65,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.74,42.78,
"Psychotherapy, 60 min",2700003,CDM,916,RC,90837,HCPCS,outpatient,,,317.7,190.62,,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,254.16,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.6,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,67.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,67.67,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,285.93,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,238.28,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.1,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,128.13,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.1,285.93,
BIOFEEDBACK,2800052,CDM,917,RC,90901,HCPCS,outpatient,,,184.95,110.97,,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,147.96,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,18.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,23.93,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,39.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,39.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,39.76,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,18.78,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,166.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.71,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,18.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,708,100,,,case rate,100% UHC case rate for outpatient setting,18.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,37.9,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,18.41,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,18.41,708,
TESTING PSYCHOTHERAPY,2700004,CDM,918,RC,,,outpatient,,,166.91,100.15,,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.53,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.89,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,150.22,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,125.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,708,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,34.2,708,
ORBICULARIS OCULI TEST (BLINK) BY EDT,2200013,CDM,920,RC,95933,HCPCS,outpatient,,,129.43,77.66,,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,103.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.72,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,27.57,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,27.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,51.56,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,116.49,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,97.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,708,100,,,case rate,100% UHC case rate for outpatient setting,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,50.55,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,26.52,708,
Sleep monitoring of patient (6 years or older) in sleep lab,2200008,CDM,920,RC,95810,HCPCS,outpatient,,,5086.49,3051.89,,3814.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4069.19,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1068.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1083.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1083.42,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2178.04,100,,,case rate,100% Anthem case rate for outpatient setting,1093.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,838.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,4577.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3814.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3814.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3814.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3814.87,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1042.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2397,100,,,case rate,100% UHC case rate for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1042.22,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,821.86,4577.84,
SLEEP STUDY < 6 YRS,2200012,CDM,920,RC,95782,HCPCS,outpatient,,,5239.08,3143.45,,3929.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,4191.26,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1068.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,1115.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1115.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2178.04,100,,,case rate,100% Anthem case rate for outpatient setting,1126.4,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,838.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,4715.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,3929.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3929.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3929.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,3929.31,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1073.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2397,100,,,case rate,100% UHC case rate for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1073.49,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,821.86,4715.17,
Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,2200009,CDM,920,RC,95811,HCPCS,outpatient,,,3279.52,1967.71,,2459.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2623.62,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,1068.41,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,698.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,698.54,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,2178.04,100,,,case rate,100% Anthem case rate for outpatient setting,705.1,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,838.29,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,2951.57,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,2459.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2459.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2459.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,2459.64,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,671.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,2397,100,,,case rate,100% UHC case rate for outpatient setting,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,671.97,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,821.86,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,671.97,2951.57,
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,2810029,CDM,921,RC,93922,HCPCS,outpatient,,,251.88,151.13,,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,201.5,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,53.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.15,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,226.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,188.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,51.61,292,
ABI WITH SEG PRESSURES,1620054,CDM,921,RC,93923,HCPCS,outpatient,,,179.22,107.53,,134.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,143.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,38.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,38.17,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,134.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,38.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,161.3,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,134.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,134.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.72,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,36.72,292,
BILATERAL MULTI SEG,2810030,CDM,921,RC,93923,HCPCS,outpatient,,,565.21,339.13,,423.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,452.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,120.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,120.39,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,423.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,121.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,508.69,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,423.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,423.91,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.81,508.69,
DUPLEX SCAN OF HEMODIALYSIS ACCESS,1600587,CDM,921,RC,93990,HCPCS,outpatient,,,595,357,,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,476,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,126.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,126.74,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,95.88,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,535.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,446.25,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,121.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,121.92,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,94,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,94,535.5,
LOWER EXTREM ARTERIAL EVAL,2810019,CDM,921,RC,93965,HCPCS,outpatient,,,434.91,260.95,,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,347.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,92.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,92.64,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,93.51,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,391.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,326.18,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.11,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,89.11,391.42,
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,2810017,CDM,921,RC,93922,HCPCS,outpatient,,,472.34,283.4,,354.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,377.87,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,100.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,100.61,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,354.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.55,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,425.11,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,354.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,354.26,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,96.78,425.11,
TCPO2 MULTIPLE SITE,2810018,CDM,921,RC,93923,HCPCS,outpatient,,,596.63,357.98,,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,127.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.28,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,536.97,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,447.47,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.25,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.25,536.97,
US ARTERIAL DOPPLER LOWER EXT BILAT,1600172,CDM,921,RC,93925,HCPCS,outpatient,,,739.23,443.54,,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,591.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,157.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,157.46,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,158.93,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,665.31,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,554.42,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,151.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,151.47,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,151.47,665.31,
US ARTERIAL DOPPLER LOWER EXT LT,1600543,CDM,921,RC,93926LT,HCPCS,outpatient,,,546.64,327.98,,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,491.98,
US ARTERIAL DOPPLER LOWER EXT RT,1600540,CDM,921,RC,93926RT,HCPCS,outpatient,,,546.64,327.98,,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,491.98,
US ARTERIAL DOPPLER UPPER EXT BILAT,1600149,CDM,921,RC,93930,HCPCS,outpatient,,,943.57,566.14,,707.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,754.86,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,200.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,200.98,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,707.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,202.87,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,849.21,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,707.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,707.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,193.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,193.34,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,193.34,849.21,
US ARTERIAL DOPPLER UPPER EXT LT,1600539,CDM,921,RC,93931LT,HCPCS,outpatient,,,505.11,303.07,,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,454.6,
US ARTERIAL DOPPLER UPPER EXT RT,1600542,CDM,921,RC,93931RT,HCPCS,outpatient,,,505.11,303.07,,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,404.09,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,454.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,378.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.5,454.6,
Study of vessels on both sides of the head and neck,1600148,CDM,921,RC,93880,HCPCS,outpatient,,,296.64,177.98,,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,237.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,63.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,63.18,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,63.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,266.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.78,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,60.78,292,
US RENAL DOPPLER,1600137,CDM,921,RC,93975,HCPCS,outpatient,,,562.75,337.65,,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,450.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,119.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,120.99,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,506.48,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,422.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,115.31,506.48,
Complete bilateral study of the extremities,1600174,CDM,921,RC,93970,HCPCS,outpatient,,,597.4,358.44,,448.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,477.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,127.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,127.25,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,448.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,128.44,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,537.66,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,448.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,448.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.41,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,122.41,537.66,
US VENOUS DOPPLER LOWER EXT LT,1600541,CDM,921,RC,93971LT,HCPCS,outpatient,,,1275.14,765.08,,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1147.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.28,1147.63,
US VENOUS DOPPLER LOWER EXT RT,1600544,CDM,921,RC,93971LT,HCPCS,outpatient,,,1275.14,765.08,,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1020.11,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,271.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,271.6,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,274.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1147.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,956.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.28,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.28,1147.63,
Complete bilateral study of the extremities,1600150,CDM,921,RC,93970,HCPCS,outpatient,,,803.71,482.23,,602.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,642.97,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,267.01,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,171.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,171.19,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,602.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,172.8,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,209.5,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,723.34,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,602.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,602.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.68,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,205.39,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,164.68,723.34,
US VENOUS DOPPLER UPPER EXT LT,1600170,CDM,921,RC,93971LT,HCPCS,outpatient,,,546.64,327.98,,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,491.98,
US VENOUS DOPPLER UPPER EXT RT,1600602,CDM,921,RC,93971RT,HCPCS,outpatient,,,546.64,327.98,,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,437.31,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,116.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,116.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,491.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,409.98,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,292,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,112.01,491.98,
Test to assess for nerve damage,2840021,CDM,922,RC,95886,HCPCS,outpatient,,,332.69,199.61,,249.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,266.15,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,70.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,70.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,249.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,71.53,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,299.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,249.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,249.52,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.17,681,
Test to assess for nerve damage,2840022,CDM,922,RC,95886,HCPCS,outpatient,,,506.75,304.05,,380.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,405.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,107.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,107.94,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,380.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.95,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,456.08,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,380.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,380.06,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,103.83,681,
EMG CRANIAL NERVE BILATERAL,2840015,CDM,922,RC,95868,HCPCS,outpatient,,,337.65,202.59,,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,270.12,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,71.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,71.92,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,72.59,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,303.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,253.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.18,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,69.18,681,
EMG CRANIAL NERVE UNILATERAL,2840014,CDM,922,RC,95867,HCPCS,outpatient,,,319.9,191.94,,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,287.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,681,
EMG FOUR EXT; WITH OR WITHOUT REL PARAS,2840011,CDM,922,RC,95864,HCPCS,outpatient,,,643.07,385.84,,482.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,514.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,136.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,136.97,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,482.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,138.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,578.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,482.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,482.3,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,131.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,131.77,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,681,
EMG LIMITED STUDY < 4 MUSCLES EXTREMITY,2840013,CDM,922,RC,95870,HCPCS,outpatient,,,165.01,99.01,,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,148.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,33.81,681,
"EMG LTD, EA EXT, WITH PARASPINAL WITH ST",2840020,CDM,922,RC,95885,HCPCS,outpatient,,,232.78,139.67,,174.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,186.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,49.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,49.58,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,174.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,209.5,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,174.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,174.59,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,47.7,681,
Test to measure electrical activity of muscles or nerves in 1 limb,2840008,CDM,922,RC,95860,HCPCS,outpatient,,,305.43,183.26,,229.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,244.34,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,65.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,65.06,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,229.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,65.67,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,274.89,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,229.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,229.07,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,62.58,681,
EMG THORACIC PARASPINALS,2840012,CDM,922,RC,9586959,HCPCS,outpatient,,,319.9,191.94,,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,287.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,65.55,681,
EMG THREE EXT; WITH OR WITHOUT REL PARAS,2840010,CDM,922,RC,95863,HCPCS,outpatient,,,530.52,318.31,,397.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,424.42,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,113,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,113,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,397.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.06,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,477.47,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,397.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,397.89,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,108.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,108.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,108.7,681,
Test to measure electrical activity of muscles or nerves in 2 limb,2840009,CDM,922,RC,95861,HCPCS,outpatient,,,417.97,250.78,,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,334.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,89.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,89.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,376.17,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,313.48,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.64,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,85.64,681,
H REFLEX; OTHER THAN GASTROBILATERAL,2840016,CDM,922,RC,9593650,HCPCS,outpatient,,,139.87,83.92,,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,681,
H REFLEX; OTHER THAN GASTROC,2840006,CDM,922,RC,95936,HCPCS,outpatient,,,139.87,83.92,,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,111.9,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,29.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,29.79,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.07,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,125.88,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,104.9,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.66,681,
H REFLEX; RECORDED FROM GASTROBILATERAL,2840017,CDM,922,RC,9593450,HCPCS,outpatient,,,164.46,98.68,,123.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,131.57,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.03,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.36,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.01,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.35,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.7,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.7,681,
H REFLEX; RECORDED FROM GASTROC,2840005,CDM,922,RC,95934,HCPCS,outpatient,,,165.01,99.01,,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,681,
MOTOR NERVE LAT/AMP EACH NERVE WITHOUT F,2840001,CDM,922,RC,9590059,HCPCS,outpatient,,,165.01,99.01,,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,681,
MOTOR WITH F WAVE,2840002,CDM,922,RC,95903,HCPCS,outpatient,,,165.01,99.01,,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,681,
MOTOR WITH F WAVE SEPARATE AND DISTINCT,2840003,CDM,922,RC,9590359,HCPCS,outpatient,,,152.71,91.63,,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,122.17,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,32.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,32.53,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.83,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,137.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,114.53,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.29,681,
NERVE CONDUCTION STUDIES 1-2,2840029,CDM,922,RC,95907,HCPCS,outpatient,,,319.9,191.94,,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,255.92,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,68.14,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,68.78,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,287.91,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,239.93,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,65.55,681,
NERVE CONDUCTION STUDIES 11-12,2840024,CDM,922,RC,95912,HCPCS,outpatient,,,1048.48,629.09,,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,552.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,223.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,433.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,943.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,943.63,
NERVE CONDUCTION STUDIES 13 OR >,2840023,CDM,922,RC,95913,HCPCS,outpatient,,,1048.48,629.09,,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,552.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,223.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,433.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,943.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,943.63,
NERVE CONDUCTION STUDIES 3-4,2840028,CDM,922,RC,95908,HCPCS,outpatient,,,284.93,170.96,,213.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,227.94,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,60.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,60.69,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,213.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,61.26,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,256.44,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,213.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,213.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.38,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,58.38,681,
NERVE CONDUCTION STUDIES 5-6,2840027,CDM,922,RC,95909,HCPCS,outpatient,,,586.26,351.76,,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,527.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,681,
NERVE CONDUCTION STUDIES 7-8,2840026,CDM,922,RC,95910,HCPCS,outpatient,,,586.26,351.76,,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,469.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,320.22,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,126.05,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,251.26,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,527.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,439.7,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,246.33,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,120.12,681,
NERVE CONDUCTION STUDIES 9-10,2840025,CDM,922,RC,95911,HCPCS,outpatient,,,1048.48,629.09,,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,838.78,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,552.77,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,223.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,223.33,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,225.42,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,433.71,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,943.63,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,786.36,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,425.21,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,214.83,943.63,
NEUROMUSCULAR JUNCTION TESTING,2840007,CDM,922,RC,95937,HCPCS,outpatient,,,326.73,196.04,,245.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,261.38,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,166.28,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,69.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,69.59,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,245.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,70.25,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,130.46,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,294.06,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,245.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,245.05,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.95,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,127.91,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,66.95,681,
SENSORY OR MIXED NERVE STUDY,2840004,CDM,922,RC,95904,HCPCS,outpatient,,,165.01,99.01,,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,132.01,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.15,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.48,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,148.51,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,123.76,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,681,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,33.81,681,
OUTPATIENT DIALYSIS,1000020,CDM,940,RC,,,outpatient,,,1807.09,1084.25,,1355.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1445.67,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,384.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,384.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,1355.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,388.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,1626.38,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,1355.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1355.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1355.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,1355.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.27,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,370.27,1626.38,
PHLEBTOMY (THERAPUTIC),1500088,CDM,940,RC,99195,HCPCS,outpatient,,,166.37,99.82,,124.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,133.1,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,132.76,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,35.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,35.44,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,124.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.77,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,104.17,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,149.73,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,124.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,124.78,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.09,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,102.12,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,34.09,502,
"Established patient office or other outpatient, visit typically 40 minutes",297533,CDM,942,RC,99215,HCPCS,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,266,
"New patient office of other outpatient visit, typically 60 min",297532,CDM,942,RC,99205,HCPCS,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,266,
Outpatient visit of established patient requiring a physician,297522,CDM,942,RC,99212,HCPCS,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,266,
"New patient office or other outpatient visit, typically 10 minutes",297521,CDM,942,RC,99202,HCPCS,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,266,
BIRTHING AND PARENTING CLASSS,1750004,CDM,942,RC,,,outpatient,,,290.67,174.4,,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,232.54,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,61.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,61.91,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,62.49,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,261.6,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,218,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.56,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,59.56,266,
COMP MGMT SKILLS PART ONE PER 30 MIN,297500,CDM,942,RC,G0109,HCPCS,outpatient,,,56.55,33.93,,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,15.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,266,
COMP MGMT SKILLS PART THREE PER 30 MIN,297511,CDM,942,RC,G0109,HCPCS,outpatient,,,56.55,33.93,,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,15.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,266,
COMP MGMT SKILLS PART TWO PER 30 MIN,297510,CDM,942,RC,G0109,HCPCS,outpatient,,,56.55,33.93,,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,45.24,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,19.21,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,12.05,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,12.16,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,15.08,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,50.9,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,42.41,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,14.78,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,11.59,266,
"Established patient office or other outpatient, visit typically 40 minutes",297512,CDM,942,RC,99215,HCPCS,outpatient,,,677.77,406.66,,508.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,542.22,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,144.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.37,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,508.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,145.72,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,609.99,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,508.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,508.33,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,138.88,609.99,
"Established patient office or other outpatient, visit typically 40 minutes",297529,CDM,942,RC,99215,HCPCS,outpatient,,,135.5,81.3,,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,266,
"New patient office of other outpatient visit, typically 60 min",297528,CDM,942,RC,99205,HCPCS,outpatient,,,135.5,81.3,,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,108.4,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,28.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,28.86,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,29.13,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,121.95,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,101.63,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,27.76,266,
Outpatient visit of established patient requiring a physician,297527,CDM,942,RC,99212,HCPCS,outpatient,,,67.75,40.65,,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,266,
"New patient office or other outpatient visit, typically 10 minutes",297526,CDM,942,RC,99202,HCPCS,outpatient,,,67.75,40.65,,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,54.2,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,14.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,14.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,14.57,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,60.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,50.81,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.88,266,
"Established patient office or other outpatient visit, typically 25 minutes",297514,CDM,942,RC,99214,HCPCS,outpatient,,,192.04,115.22,,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,266,
"New patient office of other outpatient visit, typically 45 min",297513,CDM,942,RC,99204,HCPCS,outpatient,,,192.04,115.22,,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,266,
"Established patient office or other outpatient visit, typically 25 minutes",297516,CDM,942,RC,99214,HCPCS,outpatient,,,192.04,115.22,,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,266,
"New patient office of other outpatient visit, typically 45 min",297515,CDM,942,RC,99204,HCPCS,outpatient,,,192.04,115.22,,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,153.63,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,40.9,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.29,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,172.84,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,144.03,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.35,266,
DEPT M/S SUP BARKER,4066015,CDM,942,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266,266,
DEPT M/S SUP-GRIFFIS,4066033,CDM,942,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,266,266,
"Established patient office or other outpatient visit, typically 25 minutes",297531,CDM,942,RC,99214,HCPCS,outpatient,,,101.62,60.97,,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,266,
"New patient office of other outpatient visit, typically 45 min",297530,CDM,942,RC,99204,HCPCS,outpatient,,,101.62,60.97,,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,81.3,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,21.65,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,21.85,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,91.46,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,76.22,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,20.82,266,
EXERCIZE THERAPY MODULE,297525,CDM,942,RC,,,outpatient,,,146.98,88.19,,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,117.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,31.31,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,31.6,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,132.28,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,110.24,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,30.12,266,
Outpatient visit of established patient requiring a physician,297524,CDM,942,RC,99212,HCPCS,outpatient,,,271.27,162.76,,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,266,
"New patient office or other outpatient visit, typically 10 minutes",297523,CDM,942,RC,99202,HCPCS,outpatient,,,271.27,162.76,,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,217.02,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,57.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,57.78,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,58.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,244.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,203.45,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.58,266,
"Established patient office or other outpatient, visit typically 40 minutes",297518,CDM,942,RC,99215,HCPCS,outpatient,,,259.8,155.88,,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,266,
"New patient office of other outpatient visit, typically 60 min",297517,CDM,942,RC,99205,HCPCS,outpatient,,,259.8,155.88,,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,207.84,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,55.34,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,55.86,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,233.82,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,194.85,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,53.23,266,
"Established patient office or other outpatient visit, typically 25 minutes",297520,CDM,942,RC,99214,HCPCS,outpatient,,,113.1,67.86,,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.17,266,
"New patient office of other outpatient visit, typically 45 min",297519,CDM,942,RC,99204,HCPCS,outpatient,,,113.1,67.86,,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,90.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,24.09,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,24.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,101.79,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,84.83,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,266,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.17,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,23.17,266,
CARDIAC REHAB EMPLOYEES PHASE 1V,2850004,CDM,943,RC,,,outpatient,,,44.26,26.56,,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,35.41,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,9.43,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,9.52,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,39.83,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,33.2,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,9.07,502,
Outpatient visit of established patient requiring a physician,2850001,CDM,943,RC,99212,HCPCS,outpatient,,,313.07,187.84,,234.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,250.46,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,66.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,66.68,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,234.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,67.31,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,281.76,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,234.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,234.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.15,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,64.15,502,
CARDIAC REHAB INPATIENT SERVICES,2850005,CDM,943,RC,,,outpatient,,,104.91,62.95,,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,83.93,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,22.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,22.35,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,22.56,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,94.42,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,78.68,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.5,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,21.5,502,
Use of EKG to monitor cardiac rehabilitation,2850002,CDM,943,RC,93798,HCPCS,outpatient,,,278.1,166.86,,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,222.48,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,105.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,137.29,130,,,fee schedule,130% CMS Medicare OPPS fee schedule,59.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,59.24,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,59.79,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,107.72,102,,,fee schedule,102% CMS Medicare OPPS fee schedule,250.29,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,208.58,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,105.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,105.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,56.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,105.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,56.98,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,105.61,100,,,fee schedule,100% CMS Medicare OPPS fee schedule,56.98,502,
CARDIAC REHAB UNMONITORED EXERCIZE,2850003,CDM,943,RC,,,outpatient,,,62.01,37.21,,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,49.61,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,13.21,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,13.33,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,55.81,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,46.51,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,12.71,502,
CARDIAC WELLNESS STATE HEALTH EMPLOYEE,2850007,CDM,943,RC,,,outpatient,,,55.73,33.44,,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,44.58,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,11.87,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,11.98,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,50.16,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,41.8,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,11.42,502,
CARDIAC WELLNESS TELFAIR OFFICE,2850006,CDM,943,RC,,,outpatient,,,40.16,24.1,,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,32.13,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,8.55,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,8.63,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,36.14,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,30.12,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,8.23,502,
WELLNESS COURTESY DISC,3000002,CDM,943,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502,502,
WELLNESS MONTHLY CHARGE,3000000,CDM,943,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502,502,
WELLNESS MONTHLY CHARGE MILITARY,3000001,CDM,943,RC,,,outpatient,,,,,,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting due to charge amount,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,502,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,502,502,
PULMONARY REHAB W/EXE 1 HOUR PER SESSION,5200424,CDM,948,RC,G0424,HCPCS,outpatient,,,117.76,70.66,,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,94.21,80,,,percent of total billed charges,80% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,25.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,25.08,21.3,,,percent of total billed charges,21.3% of billed charges which is 106% of the GA Medicaid OP CCR rate,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,25.32,21.5,,,percent of total billed charges,21.5% of billed charges which is 107% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,105.98,90,,,percent of total billed charges,90% of total billed charges for outpatient setting,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,88.32,75,,,percent of total billed charges,75% of total billed charges for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,388,100,,,case rate,100% UHC case rate for outpatient setting,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.13,20.49,,,percent of total billed charges,20.49% of billed charges which is 102% of the GA Medicaid OP CCR rate,,,,,other,Not separately reimbursable for outpatient setting per CMS guidelines,24.13,388,
ABDOMINOPERINEAL RESECTION,200844,CDM,964,RC,00844QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
AMNIOCENTESIS,200842,CDM,964,RC,00842QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
AMPUTATION,201232,CDM,964,RC,01232QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANES FOR CLOSED PROC INVOL HIP JOINT,201200,CDM,964,RC,01200QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANES FOR EXTRAPERITONEAL LOW ABD INC URI,200860,CDM,964,RC,00860QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANES FOR HERNIA REP LOW ABD NOT OW SPEC,200830,CDM,964,RC,00830QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANES FOR OPEN PROC INV HIP JOINT,201210,CDM,964,RC,01210QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANES FOR PROC INV VEINS OF UPP LEG,201260,CDM,964,RC,01260QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANES FOR PROD MAJOR ABD VESSELS,200880,CDM,964,RC,00880QZ,HCPCS,outpatient,,,1396.23,837.74,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANES. BLOCKS 15/UNIT,2000001,CDM,964,RC,,,outpatient,,,113.37,68.02,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANES. PROF. 15/UNIT,2000002,CDM,964,RC,,,outpatient,,,110.09,66.05,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FACIAL BONE SURGERY,200190,CDM,964,RC,00190QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR ACCESS TO CENTRAL VEN CIRC,200532,CDM,964,RC,00532QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR ALL PROC ON MAJ ABD BLD VESS,200770,CDM,964,RC,00770QZ,HCPCS,outpatient,,,1438.3,862.98,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR CLOSED CHEST PROC NOT OTH SPEC,200520,CDM,964,RC,00520QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR HERNIA REPAIR IN UPP ABDOMEN,200750,CDM,964,RC,00750QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR INTESTINAL ENDOSCOPIC PROC,200810,CDM,964,RC,00811QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR INTRAPERITONEAL INCL LAPR,200790,CDM,964,RC,00790QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR INTRAPERITONEAL LOW ABD IN LAP,200840,CDM,964,RC,00840QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR LUMBAR PUNCTURE,200635,CDM,964,RC,00635QZ,HCPCS,outpatient,,,643.07,385.84,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR PROC IN LUMBAR REGION,200630,CDM,964,RC,630,HCPCS,outpatient,,,744.7,446.82,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR PROC MAJOR VESSELS OF NECK,200350,CDM,964,RC,00350QZ,HCPCS,outpatient,,,931.01,558.61,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR PROC OF INTEGUMENTARY NECK,200300,CDM,964,RC,00300QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"ANEST FOR PROC ON ESOPH,THYROID",200320,CDM,964,RC,00320QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"ANEST FOR PROC ON INTEG HEAD,NECK TRUCK0",200100,CDM,964,RC,00300QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR PROC ON INTEGUMENTARY OF EXTRE,200400,CDM,964,RC,00400QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR PROC ON LOW ANTERIOR ABD WALL,200800,CDM,964,RC,00800QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR PROC ON LOW POSTERIOR ABD WALL,200820,CDM,964,RC,00820QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR PROC ON NOSE,200160,CDM,964,RC,00160QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR PROC ON UPPER ANT ABD WALL,200700,CDM,964,RC,00700QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR THORACOTOMY PROC INCL LUNGS,200540,CDM,964,RC,00540QZ,HCPCS,outpatient,,,1210.2,726.12,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR TRANS PACEMAKER INSERTION,200530,CDM,964,RC,00530QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR TRANSURETHRAL PROC,200910,CDM,964,RC,00910QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR UPPER GASTROINTESTINAL ENDO,200740,CDM,964,RC,00731QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANEST FOR VAG PROC INCL BIOPSY LABIA,200940,CDM,964,RC,00940QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH ARTERIES OF KNEE AND POPLITEAL,201440,CDM,964,RC,01440QZ,HCPCS,outpatient,,,744.7,446.82,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH CORNEAL TRANSPLANT,200144,CDM,964,RC,00144QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH EAR SURGERY,200120,CDM,964,RC,00120QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH FOR ANTHROSCOPIC PROC ANKLE OR FO,201464,CDM,964,RC,01470QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH FOR BONY PELVIS,201120,CDM,964,RC,01120QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH FOR CLOSED REDUCTION HIP,201160,CDM,964,RC,01160QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH FOR PROC ON MOUTH,200170,CDM,964,RC,00170QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH FOR PROC ON UPPER ARM AND ELBOW,201710,CDM,964,RC,01710QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH FOR VASECTOMY,200869,CDM,964,RC,00921QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH LENS SURGERY,200142,CDM,964,RC,00142QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH PERINEAL SURGERY,200904,CDM,964,RC,00904QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTH PROC ON EYE,200140,CDM,964,RC,00140QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"ANESTH, PHARYNGEAL EXC TUMOR",200174,CDM,964,RC,00174QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"ANESTH, UPPER LEG SURGERY",201250,CDM,964,RC,01250QZ,HCPCS,outpatient,,,383.55,230.13,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"ANESTH,PHARYNGEAL SURGERY RADICAL",200176,CDM,964,RC,00176QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA FOR ABORTION PROCEDURES,201964,CDM,964,RC,01965QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA FOR ABORTION PROCEDURES,201965,CDM,964,RC,01965QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA FOR EAR EXAM,200124,CDM,964,RC,00124QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA FOR INDUCED ABORTION PROC,201966,CDM,964,RC,01966QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA OPEN PROC HUMERAL HEAD NECK,201630,CDM,964,RC,01630QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA OPEN PROC LOWER 3RD FEMUR,201360,CDM,964,RC,01360QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA OPEN PROC TIBIA PATELLA FIBUL,201392,CDM,964,RC,01392QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA TIME PER MINUTE,200099,CDM,964,RC,,,outpatient,,,7.11,4.27,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANESTHESIA UPPER LEG SKIN,201240,CDM,964,RC,00400QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ANORECTAL PROC INCL ENDOSCOPY OR BIOPSY,200902,CDM,964,RC,00902QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ARTERIAL CATHERIZATION,201923,CDM,964,RC,36620,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ARTERIOVENOUS FISTULA,201432,CDM,964,RC,01432QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
ARTHO0 090902,201740,CDM,964,RC,01740QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
AXILLARY NERVE BLOCK,264417,CDM,964,RC,64417QZ,HCPCS,outpatient,,,1610.95,966.57,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
AXILLARY-BRACHIAL ANEURYSM,201652,CDM,964,RC,01652QZ,HCPCS,outpatient,,,931.01,558.61,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
AXILLARY-FEMORAL BYPASS GRAFT,201656,CDM,964,RC,01656QZ,HCPCS,outpatient,,,930.73,558.44,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
BLOOD PATCH,262273,CDM,964,RC,62273QZ,HCPCS,outpatient,,,1278.77,767.26,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
BYPASS GRAFT,201654,CDM,964,RC,01654QZ,HCPCS,outpatient,,,744.7,446.82,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CARDIOVERSION,200410,CDM,964,RC,00410QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CASEAREAN HYSTERECTOMY,200855,CDM,964,RC,01963QZ,HCPCS,outpatient,,,930.73,558.44,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CERVICAL CERCLAGE,200948,CDM,964,RC,00948QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CESAREAN SECTION,200850,CDM,964,RC,01961QZ,HCPCS,outpatient,,,671.21,402.73,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CLOSED PROC ON KNEE JOINT,201380,CDM,964,RC,01380QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CLOSED PROC ON RADIUS ULNA AND HAND BON,201820,CDM,964,RC,01820QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"CLOSED PROC ON UP ENDS TIBIA,FIBULA,PATE",201390,CDM,964,RC,01390QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"CLOSED PROCEDURES ON HUMERAL,SHOULDER",201620,CDM,964,RC,01620QZ,HCPCS,outpatient,,,383.55,230.13,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CLOSED PROCEDURES ON UPPER 2/3 OF FEMUR,201220,CDM,964,RC,01220QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"COLPOTOMY, COLPECTOMY, COLPORRHAPHY",200942,CDM,964,RC,00942QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CONT EPIDURAL ANALG LAB AND VAG DELIVERY,200955,CDM,964,RC,01967QZ,HCPCS,outpatient,,,931.01,558.61,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CONT EPIDURAL LABOR AND C SECT,200857,CDM,964,RC,01968QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CULDOSCOPY,200950,CDM,964,RC,00950QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
CYSTOLITHOTOMY,200870,CDM,964,RC,00870QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
DAILY HOSP MGMT OF IV PCA,201924,CDM,964,RC,01991QZ,HCPCS,outpatient,,,186.04,111.62,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
DAILY MGMT EPIDURAL/SPINAL DRUG ADMIN,201996,CDM,964,RC,01996QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
DISARTICULATION AT KNEE,201404,CDM,964,RC,01404QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
EMBOLECTOMY,201772,CDM,964,RC,01772QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
EMBOLECTOMY,201842,CDM,964,RC,01842QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"EMBOLECTOMY, DIRECT OR CATHETER 0",201502,CDM,964,RC,01502QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
EMERGENCY CONDITIONS,200095,CDM,964,RC,99140,HCPCS,outpatient,,,186.04,111.62,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
EMERGENCY INTUBATION,202000,CDM,964,RC,31500QZ,HCPCS,outpatient,,,562.75,337.65,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
EXTREME AGE UNDER ONE YR OR OVER 70 YRS,200094,CDM,964,RC,99100,HCPCS,outpatient,,,186.04,111.62,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
FEMORAL ARTERY EMBOLECTOMY,201274,CDM,964,RC,01274QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
HERNIA REPAIR LOWER ABD UNDER 1 YR,200834,CDM,964,RC,00834QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
HERNIA REPAIR LOWER ABD UNDER 1 YR,200854,CDM,964,RC,,,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
HYSTERECTOMY RADICAL,200846,CDM,964,RC,00846QZ,HCPCS,outpatient,,,744.7,446.82,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
HYSTEROSCOPY,200952,CDM,964,RC,00952QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,209999,CDM,964,RC,62322,HCPCS,outpatient,,,1278.77,767.26,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
INTEGUMENTARY EXTREMETIES,201460,CDM,964,RC,00400QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"INTEGUMENTARY FOREARM,WRIST HAND",201800,CDM,964,RC,00400QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
INTEGUMENTARY KNEE,201300,CDM,964,RC,00400QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"INTEGUMENTARY OF EXTR, ANTERIOR TRUNK",201000,CDM,964,RC,00400QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
INTEGUMENTARY OF UPPER ARM AND ELBOW,201700,CDM,964,RC,00400QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"INTEGUMENTARY,MUSCLES HEAD,NECK,TRUNK",201110,CDM,964,RC,00300QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
KNEE JOINT PROCEDURE,201400,CDM,964,RC,01400QZ,HCPCS,outpatient,,,383.55,230.13,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
KNEE PROCEDURES,201320,CDM,964,RC,01320QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
LIMITED CONSULTATION,200090,CDM,964,RC,99201,HCPCS,outpatient,,,93.15,55.89,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"LOWER LEG CAST APPLICATION,REMOVAL",201490,CDM,964,RC,01490QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
LOWER LEG RADICAL RESECTION (BKA),201482,CDM,964,RC,01482QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"LOWER LEG,ANKLE,FOOT SURGERY ANESTH",201470,CDM,964,RC,01470QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
LUMBAR AND VENTRAL HERNIAS OR WOUND,200752,CDM,964,RC,00752QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,262311,CDM,964,RC,62322,HCPCS,outpatient,,,1278.77,767.26,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
LUMBAR SYMPATHECTOMY,200632,CDM,964,RC,00632QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
NEEDLE BIOPSY OF THYROID,200322,CDM,964,RC,00322QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
NERVE BLOCK CERVICAL PLEXUS,264413,CDM,964,RC,64999,HCPCS,outpatient,,,1278.77,767.26,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
NERVE BLOCK FEMORAL SINGLE,264447,CDM,964,RC,64447QZ,HCPCS,outpatient,,,1278.77,767.26,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
NERVE BLOCK OTHER THAN PRONE POSITION,200097,CDM,964,RC,1991,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
NERVE BLOCK PRONE POSITION,200098,CDM,964,RC,1992,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
OMPHALOCELE,200754,CDM,964,RC,00754QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"OPEN PROC ON RADIUS,ULNA,WRIST,HAND",201830,CDM,964,RC,01830QZ,HCPCS,outpatient,,,314.16,188.5,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
OPEN PROC UPPER FEMUR,201230,CDM,964,RC,01230QZ,HCPCS,outpatient,,,488.72,293.23,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
OPEN PROCEDURES BONES OF LOWER LEG,201480,CDM,964,RC,01480QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
P3- A PATIENT WITH SEVERE SYSTEMIC DIS,200091,CDM,964,RC,P3,HCPCS,outpatient,,,93.15,55.89,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
P4-SEVERE SYSTEMIC DIS WITH THREAT TO LI,200092,CDM,964,RC,P4,HCPCS,outpatient,,,186.04,111.62,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
P5-A MORIBUND PT NOT EXP TO SURVIVE W/O,200093,CDM,964,RC,P5,HCPCS,outpatient,,,287.66,172.6,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PANCREATECTOMY PART OR TOTAL (WHIPPLE),200794,CDM,964,RC,00794QZ,HCPCS,outpatient,,,744.7,446.82,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PARTIAL HEPATECTOMY EXC LIVER BIOPSY,200792,CDM,964,RC,00792QZ,HCPCS,outpatient,,,1210.2,726.12,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PERCUTANEOUS LIVER BIOPSY,200702,CDM,964,RC,00702QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
POPLITEAL THROMBOENDARTERECTOMY,201442,CDM,964,RC,01442QZ,HCPCS,outpatient,,,744.7,446.82,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PROC INV ARTERIE OF UPP LEG INCL GRAFT,201270,CDM,964,RC,01270QZ,HCPCS,outpatient,,,744.7,446.82,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PROC OF ARTERIES OF UPPER ARM,201784,CDM,964,RC,01770QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PROC ON MALE EXTERNAL GENITALIA,200920,CDM,964,RC,00920QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"PROC ON NERVES,MUSCLES,TENDONS FACE WRIS",201810,CDM,964,RC,01810QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PROC ON PERINEAL INTEGUMENTARY SYSTEM,200900,CDM,964,RC,00400QZ,HCPCS,outpatient,,,287.66,172.6,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PROC ON VEINS OF KNEE AND POPLITEAL AREA,201430,CDM,964,RC,01430QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"PROCEDURES NERVES, MUSCLES TENDONS SHOUL",201610,CDM,964,RC,01610QZ,HCPCS,outpatient,,,407.31,244.39,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PROCEDURES ON ARTERIES LOWER LEG 0,201500,CDM,964,RC,01500QZ,HCPCS,outpatient,,,744.7,446.82,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"PROCEDURES ON ARTERIES OF SHOULDER,AXILL",201650,CDM,964,RC,01650QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"PROCEDURES ON ARTERIES OF UPPER ARM,ELBO",201770,CDM,964,RC,01770QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PROCEDURES ON CLAVICLE AND SCAPULA NOS,200450,CDM,964,RC,00450QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"PROCEDURES ON VEINS OF FOREARM,WRIST,HAN",201850,CDM,964,RC,01850QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
PROCEDURES ON VEINS OF LOWER LEG,201520,CDM,964,RC,01520QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"RADICAL ORCHIECTOMY, ABDOMINAL",200928,CDM,964,RC,00928QZ,HCPCS,outpatient,,,575.33,345.2,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"RADICAL ORCHIECTOMY, INGUINAL",200926,CDM,964,RC,00926QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
RADICAL PROC OF BREAST,200404,CDM,964,RC,00404QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
RADICAL PROC OF BREAST WITH MAMMARY NODE,200406,CDM,964,RC,00406QZ,HCPCS,outpatient,,,1209.92,725.95,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
RADIOLOGICAL EXAM,201922,CDM,964,RC,01922QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
RENAL PROC UPPER 1/3 URETER,200862,CDM,964,RC,00862QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
REPAIR OF NONUNION OR MALUNION OF HUMERU,201744,CDM,964,RC,01744QZ,HCPCS,outpatient,,,488.72,293.23,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
REVISION OF TOTAL HIP ARTHROPLASTY,201215,CDM,964,RC,01215QZ,HCPCS,outpatient,,,814.64,488.78,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
SEMINAL VESICLES,200922,CDM,964,RC,00922QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
SIMPLE LIGATION,200352,CDM,964,RC,00352QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
SKIN PROCEDURES,201600,CDM,964,RC,00400QZ,HCPCS,outpatient,,,279.2,167.52,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
THERAPEUTIC INTERVENTIONAL RAD PROC,200884,CDM,964,RC,01930QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
TOTAL HIP ARTHROPLASTY,201214,CDM,964,RC,01214QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
TOTAL KNEE ARTHROPLASTY,201402,CDM,964,RC,01402QZ,HCPCS,outpatient,,,570.13,342.08,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
TRANSABDOMINAL REPAIR OF DIAPHRAG HERNIA,200756,CDM,964,RC,00756QZ,HCPCS,outpatient,,,651.54,390.92,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
TUBAL LIGATION/ TRANSECTION,200851,CDM,964,RC,00851QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
UNDESCENDED TESTIS UNILAT OR BILAT,200924,CDM,964,RC,00924QZ,HCPCS,outpatient,,,372.35,223.41,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
VAGINAL DELIVERY,200946,CDM,964,RC,01960QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
VAGINAL HYSTERECTOMY,200944,CDM,964,RC,00944QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"VASCULAR SHUNT,REVISION,ANY TYPE",201844,CDM,964,RC,01844QZ,HCPCS,outpatient,,,575.33,345.2,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
VENIPUNCTURE < 3 YEARS FEM OR ING,201925,CDM,964,RC,36400,HCPCS,outpatient,,,186.04,111.62,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
VENIPUNCTURE > 3 YEARS,201926,CDM,964,RC,36410,HCPCS,outpatient,,,186.04,111.62,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
"VENOUS THROMBECTOMY, DIRECT OR CATHETER",201522,CDM,964,RC,01522QZ,HCPCS,outpatient,,,465.5,279.3,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
VENTRAL AND INCISIONAL HERNIAS,200832,CDM,964,RC,00832QZ,HCPCS,outpatient,,,558.38,335.03,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
TREADMILL PROF FEE,1800005,CDM,969,RC,93018,HCPCS,outpatient,,,350.49,210.29,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
EKG PRO FEE,1800004,CDM,985,RC,93010,HCPCS,outpatient,,,54.91,32.95,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
Pacemaker Interrogation,2593289,CDM,985,RC,93288,HCPCS,outpatient,,,55.17,33.1,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
RHYTHM STRIP PROF FEE,1800008,CDM,985,RC,93010,HCPCS,outpatient,,,41.52,24.91,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
EEG PRO FEE/D/C 031692,2200006,CDM,986,RC,,,outpatient,,,169.37,101.62,,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,,,other,Not separately reimbursable for physician setting,,,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,1,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,176908.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,229981.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,137636.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,137636.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,141607.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,180446.91,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,176908.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,176908.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,134990.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,501338.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,176908.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,132343.13,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,176908.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,132343.13,501338.33,
HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,2,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,80570.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,104741.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,92676.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,92676.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,95350.28,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,82181.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,80570.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,80570.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,90894.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,239982.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,80570.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,89112.41,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,80570.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,80570.25,239982.86,
"ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES",3,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,139433.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,181263.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,136657.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,136657.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,140599.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,142222.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,139433.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,139433.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,134029.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,360463.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,139433.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,131401.07,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,139433.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,131401.07,360463.23,
"TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES",4,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,96497.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,125447.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,98440.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,98440.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,101280.19,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,98427.88,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,96497.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,96497.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,96547.54,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,244589.04,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,96497.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,94654.39,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,96497.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,94654.39,244589.04,
LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,5,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,68286.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,88771.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,204919.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,204919.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,210831.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,69651.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,68286.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,68286.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,200979.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,203181.48,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,68286.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,197038.4,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,68286.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,68286.12,210831.08,
LIVER TRANSPLANT WITHOUT MCC,6,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32531.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42290.35,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,93368.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,93368.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,96062.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,33181.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32531.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32531.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,91573.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,85663.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,32531.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,89777.89,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,32531.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32531.04,96062.34,
LUNG TRANSPLANT,7,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,104929.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,66651.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,66651.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,68573.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,82329.17,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,65369.34,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,217436.43,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,64087.55,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,64087.55,217436.43,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,8,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,35286.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45871.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,59174.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,59174.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,60881.82,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,35991.79,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,35286.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35286.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,58036.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,99588.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,35286.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,56898.9,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,35286.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35286.07,99588.67,
PANCREAS TRANSPLANT,10,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32379.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42093.9,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,32764.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,32764.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33709.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,33027.52,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32379.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32379.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32134.51,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,73862.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,32379.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31504.4,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,32379.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31504.4,73862.8,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC",11,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34602.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44983.25,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,29000.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,29000.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29837,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,35294.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34602.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34602.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28442.77,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,92002.54,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,34602.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27885.05,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,34602.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27885.05,92002.54,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC",12,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27135.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35275.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,28094.12,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,28094.12,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28904.53,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,27677.82,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27135.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27135.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27553.87,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,69636.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,27135.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27013.58,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,27135.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27013.58,69636.01,
"TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC",13,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18579.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24153.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14200.23,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14200.23,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14609.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18951.08,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18579.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18579.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13927.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,50377.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18579.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13654.07,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,18579.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13654.07,50377.68,
ALLOGENEIC BONE MARROW TRANSPLANT,14,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,75490.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,98138.08,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,165557.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,165557.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,170333.15,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,77000.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,75490.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,75490.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,162373.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,199369.72,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,75490.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,159189.86,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,75490.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,75490.83,199369.72,
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,16,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53588.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,47370.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,47370.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,48737.04,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,42046.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,46459.64,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,108375.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45548.64,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41222.22,108375.33,
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,17,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53588.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,21564.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,21564.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22187.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,42046.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21150.27,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,77840.22,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20735.55,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,41222.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20735.55,77840.22,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,18,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,240103.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,312134.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,244905.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,240103.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,240103.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,643818.3,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,240103.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,240103.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,240103.84,643818.3,
SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,19,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,53003.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,68904,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,54063.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,53003.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53003.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,127081.5,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,53003.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,53003.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53003.08,127081.5,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,20,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,55979.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,72773.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,66173.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,66173.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,68082.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,57098.87,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,55979.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,55979.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,64901.33,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,165710.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,55979.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,63628.71,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,55979.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,55979.28,165710.38,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,21,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40991.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53288.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,41392.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,41392.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,42586.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,41811.18,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40991.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40991.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40596.06,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,120929.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,40991.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39800.03,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,40991.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39800.03,120929.23,
INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,22,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26602.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34582.61,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,28411.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,28411.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29231.38,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,27134.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26602.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26602.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27865.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,77633.6,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,26602.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27319.05,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,26602.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26602.01,77633.6,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,23,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,37926.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,49304.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,39146.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,39146.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40276.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,38684.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,37926.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37926.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38394.11,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,102087.7,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,37926.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37641.26,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,37926.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37641.26,102087.7,
CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,24,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25733.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33453.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,21454.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,21454.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22073.74,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,26248.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25733.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25733.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21042.27,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,70336.03,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,25733.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20629.66,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,25733.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20629.66,70336.03,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,25,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29801.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38741.7,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,33682.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,33682.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34653.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,30397.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29801.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29801.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33034.54,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,80875.39,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,29801.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32386.78,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,29801.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29801.31,80875.39,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,26,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20313.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26407.81,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,22774.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,22774.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23431.93,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20719.97,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20313.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20313.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22337,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,53854.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20313.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21899,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,20313.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20313.7,53854.58,
CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,27,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16939.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22021.95,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17746.11,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17746.11,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18258.02,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17278.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16939.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16939.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17404.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,44448.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16939.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17063.57,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,16939.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16939.96,44448.06,
SPINAL PROCEDURES WITH MCC,28,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40243.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,52316.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,33484.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,33484.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34450.6,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,41048.44,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40243.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40243.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32840.79,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,104690.03,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,40243.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32196.83,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,40243.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32196.83,104690.03,
SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,29,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23394.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30413.44,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,20890.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,20890.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21493.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23862.85,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23394.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23394.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20489.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,60874.29,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23394.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20087.4,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,23394.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20087.4,60874.29,
SPINAL PROCEDURES WITHOUT CC/MCC,30,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16201.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21061.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13965.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13965.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14368.84,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16525.29,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16201.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16201.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13697.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41701.45,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16201.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13428.82,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,16201.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13428.82,41701.45,
VENTRICULAR SHUNT PROCEDURES WITH MCC,31,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27859.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36217.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16829.78,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16829.78,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17315.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,28416.75,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27859.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27859.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16506.14,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,73403.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,27859.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16182.48,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,27859.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16182.48,73403.25,
VENTRICULAR SHUNT PROCEDURES WITH CC,32,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15129.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19668.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10779.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10779.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11090.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15432.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15129.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15129.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10571.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36594.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15129.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10364.57,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15129.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10364.57,36594.75,
VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,33,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11686.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15192.75,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8869.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8869.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9124.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11920.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11686.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11686.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8698.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30253.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11686.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8527.94,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11686.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8527.94,30253.68,
CAROTID ARTERY STENT PROCEDURES WITH MCC,34,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26463.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34403.03,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,29250.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,29250.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30094.5,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,26993.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26463.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26463.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28688.23,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,71237.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,26463.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28125.7,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,26463.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26463.87,71237.31,
CAROTID ARTERY STENT PROCEDURES WITH CC,35,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16074.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20897.23,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13504.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13504.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13894.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16396.29,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16074.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16074.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13245.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,40679.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16074.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12985.39,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,16074.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12985.39,40679.05,
CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,36,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12888.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16755.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8736.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8736.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8988.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13146.25,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12888.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12888.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8568.24,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33499.03,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12888.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8400.23,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12888.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8400.23,33499.03,
EXTRACRANIAL PROCEDURES WITH MCC,37,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23053.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29969.95,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17951,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17951,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18468.83,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23514.89,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23053.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23053.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17605.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,60079.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23053.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17260.58,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,23053.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17260.58,60079.88,
EXTRACRANIAL PROCEDURES WITH CC,38,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11537.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14998.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12203.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12203.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12555.4,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11768.32,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11537.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11537.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11968.7,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29131.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11537.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11734.01,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11537.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11537.57,29131.53,
EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,39,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8561.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11129.78,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7636.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7636.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7856.65,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8732.6,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8561.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8561.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7489.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20531.89,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8561.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7342.66,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8561.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7342.66,20531.89,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC",40,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26133.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33973.9,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19785.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19785.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20355.74,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,26656.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26133.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26133.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19404.55,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,67478.98,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,26133.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19024.06,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,26133.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19024.06,67478.98,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR",41,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15628.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20317.17,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19277.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19277.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19833.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15941.16,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15628.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15628.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18907.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41646.24,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15628.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18536.34,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15628.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15628.59,41646.24,
"PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC",42,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12444.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16178.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9649.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9649.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9927.59,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12693.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12444.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12444.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9463.69,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32946.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12444.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9278.12,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12444.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9278.12,32946.86,
SPINAL DISORDERS AND INJURIES WITH CC/MCC,52,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13772.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17904.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,52309.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,52309.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,53818.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14047.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13772.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13772.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,51303.42,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31710.7,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13772.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,50297.44,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13772.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13772.45,53818.25,
SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,53,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9804.42,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5427.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5427.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5583.84,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7692.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5322.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18218.11,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5218.54,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5218.54,18218.11,
NERVOUS SYSTEM NEOPLASMS WITH MCC,54,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10717.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13933.14,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11377.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11377.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11706.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10932.16,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10717.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10717.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11159.01,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24705.24,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10717.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10940.2,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10717.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10717.8,24705.24,
NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,55,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8121.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10558.17,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9067.94,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9067.94,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9329.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8284.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8121.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8121.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8893.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17959.84,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8121.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8719.17,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8121.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8121.67,17959.84,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,56,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16687.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21693.98,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19496.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19496.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20058.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17021.43,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16687.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16687.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19121.12,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39735.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16687.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18746.19,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,16687.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16687.68,39735.01,
DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,57,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10002.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13003.17,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10661.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10661.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10968.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10202.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10002.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10002.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10456.01,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23182.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10002.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10250.98,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10002.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10002.44,23182.32,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,58,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12367.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16078.01,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8744.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8744.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8997.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12615.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12367.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12367.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8576.75,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30731.04,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12367.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8408.58,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12367.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8408.58,30731.04,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,59,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8861.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11519.31,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8725.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8725.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8977.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9038.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8861.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8861.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8557.77,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20368.02,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8861.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8389.96,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8861.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8389.96,20368.02,
MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,60,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6981.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9075.98,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5669.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5669.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5833.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7121.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6981.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6981.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5560.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16143.02,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6981.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5451.49,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6981.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5451.49,16143.02,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC",61,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19338.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25140.62,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15450.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15450.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15895.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19725.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19338.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19338.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15153.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,52235.47,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19338.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14856.03,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,19338.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14856.03,52235.47,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC",62,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13300.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17290.42,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11283.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11283.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11609.19,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13566.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13300.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13300.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11066.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34149.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13300.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10849.71,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13300.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10849.71,34149.17,
"ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC",63,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10804.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14045.27,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9941.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9941.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10228.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11020.13,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10804.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10804.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9750.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28160.77,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10804.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9559.2,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10804.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9559.2,28160.77,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,64,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14151.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18397.41,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17924.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17924.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18442.05,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14434.89,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14151.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14151.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17580.28,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35125.26,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14151.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17235.56,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14151.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14151.85,35125.26,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,65,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7753.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10079.28,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9688.62,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9688.62,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9968.1,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7908.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7753.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7753.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9502.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18104.12,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7753.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9315.98,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7753.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7753.29,18104.12,
INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,66,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5620.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7306.27,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5474,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5474,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5631.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5732.61,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5620.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5620.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5368.73,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12441.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5620.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5263.46,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5620.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5263.46,12441.68,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,67,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10350.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13455.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7549.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7549.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7767.38,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10557.73,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10350.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10350.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7404.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25187.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10350.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7259.24,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10350.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7259.24,25187.95,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,68,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6810.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8853.39,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5284.46,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5284.46,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5436.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6946.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6810.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6810.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5182.84,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16096.7,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6810.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5081.21,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6810.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5081.21,16096.7,
TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,69,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8243.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5071.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5071.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5217.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6468.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4974.03,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14212.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4876.5,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4876.5,14212.19,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,70,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12767.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16597.37,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12641.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12641.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13006.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13022.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12767.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12767.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12398.75,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30711.45,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12767.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12155.63,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12767.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12155.63,30711.45,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,71,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8047.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10462.05,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8050.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8050.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8282.37,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8208.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8047.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8047.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7895.35,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19041.03,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8047.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7740.54,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8047.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7740.54,19041.03,
NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,72,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6239.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8111.44,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4541.64,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4541.64,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4672.65,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6364.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6239.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6239.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4454.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13750.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6239.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4366.97,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6239.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4366.97,13750.86,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,73,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10973.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14266.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9972.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9972.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10259.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11193.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10973.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10973.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9780.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26705.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10973.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9588.71,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10973.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9588.71,26705.53,
CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,74,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7816.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10161.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6330.94,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6330.94,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6513.56,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7973.18,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7816.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7816.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6209.19,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18232.36,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7816.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6087.44,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7816.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6087.44,18232.36,
VIRAL MENINGITIS WITH CC/MCC,75,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13573.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17645.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6182.78,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6182.78,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6361.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13844.81,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13573.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13573.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6063.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32506.9,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13573.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5944.98,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13573.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5944.98,32506.9,
VIRAL MENINGITIS WITHOUT CC/MCC,76,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7144.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9287.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3689.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3689.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3795.8,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7287.19,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7144.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7144.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3618.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17585.79,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7144.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3547.48,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7144.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3547.48,17585.79,
HYPERTENSIVE ENCEPHALOPATHY WITH MCC,77,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10960.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14248.46,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7268.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7268.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7478.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11179.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10960.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10960.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7128.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27861.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10960.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6989.07,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10960.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6989.07,27861.53,
HYPERTENSIVE ENCEPHALOPATHY WITH CC,78,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7756.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10083.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6633.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6633.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6824.61,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7911.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7756.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7756.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6505.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17683.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7756.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6378.14,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7756.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6378.14,17683.75,
HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,79,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5965.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7755.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4444.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4444.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4573.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6085.21,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5965.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5965.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4359.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13072.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5965.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4273.92,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5965.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4273.92,13072.23,
NONTRAUMATIC STUPOR AND COMA WITH MCC,80,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15485.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20131.68,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5253.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5253.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5404.62,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15795.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15485.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15485.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5152.07,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36332.92,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15485.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5051.05,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15485.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5051.05,36332.92,
NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,81,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7060,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9178,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3508.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3508.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3609.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7201.2,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7060,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7060,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3441.04,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16004.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7060,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3373.57,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7060,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3373.57,16004.08,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,82,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15937.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20718.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11945.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11945.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12289.66,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16256.06,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15937.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15937.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11715.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,40349.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15937.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11485.67,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15937.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11485.67,40349.52,
TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,83,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9958.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12945.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7950.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7950.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8180.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10157.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9958.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9958.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7797.82,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24014.14,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9958.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7644.92,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9958.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7644.92,24014.14,
TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,84,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7126.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9263.98,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5865.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5865.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6034.28,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7268.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7126.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7126.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5752.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16324.7,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7126.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5639.51,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7126.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5639.51,16324.7,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,85,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15901.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20672.15,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10360.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10360.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10659.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16219.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15901.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15901.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10161.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41603.49,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15901.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9962.2,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15901.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9962.2,41603.49,
TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,86,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9703.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12614.52,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5781,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5781,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5947.76,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9897.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9703.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9703.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5669.83,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23150.26,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9703.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5558.66,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9703.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5558.66,23150.26,
TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,87,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6908.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8981.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4470.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4470.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4599.87,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7047.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6908.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6908.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4384.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15539.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6908.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4298.94,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6908.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4298.94,15539.19,
CONCUSSION WITH MCC,88,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11108.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14441.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8950.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8950.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9208.66,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11331.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11108.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11108.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8778.36,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28077.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11108.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8606.23,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11108.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8606.23,28077.06,
CONCUSSION WITH CC,89,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8619.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11204.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7171.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7171.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7378.74,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8791.48,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8619.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8619.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7033.94,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20799.07,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8619.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6896.02,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8619.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6896.02,20799.07,
CONCUSSION WITHOUT CC/MCC,90,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7224.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9391.29,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4273.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4273.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4396.62,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7368.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7224.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7224.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4191.17,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14661.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7224.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4108.99,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7224.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4108.99,14661.06,
OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,91,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12765.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16594.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15383.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15383.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15827.28,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13020.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12765.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12765.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15087.7,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30768.45,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12765.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14791.85,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12765.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12765.26,30768.45,
OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,92,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7816.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10161.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7656.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7656.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7877.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7972.52,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7816.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7816.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7509.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17710.47,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7816.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7361.92,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7816.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7361.92,17710.47,
OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,93,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6183.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8038.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5601.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5601.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5763.05,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6307.48,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6183.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6183.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5493.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13622.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6183.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5386.03,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6183.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5386.03,13622.62,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,94,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24656.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32053.29,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,30713.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,30713.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31599.63,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25149.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24656.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24656.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30123.04,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,63651.18,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24656.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29532.37,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,24656.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24656.38,63651.18,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,95,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16624.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21611.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,24578.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,24578.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25287.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16956.6,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16624.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16624.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24106.28,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,45541.72,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16624.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23633.6,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,16624.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16624.12,45541.72,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,96,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15297.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19887.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13073.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13073.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13450.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15603.8,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15297.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15297.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12822.25,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,40687.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15297.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12570.83,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15297.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12570.83,40687.95,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,97,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24748.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32173.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,23360.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,23360.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24034.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25243.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24748.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24748.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22911.7,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,69256.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24748.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22462.44,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,24748.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22462.44,69256.62,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,98,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15134.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19674.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13509.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13509.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13899.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15437.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15134.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15134.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13249.68,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37123.77,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15134.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12989.88,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15134.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12989.88,37123.77,
NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,99,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9723.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12640.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6575.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6575.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6764.88,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9918.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9723.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9723.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6448.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24910.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9723.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6322.31,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9723.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6322.31,24910.08,
SEIZURES WITH MCC,100,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14018.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18224.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11333.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11333.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11660.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14299.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14018.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14018.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11115.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34216.85,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14018.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10897.84,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14018.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10897.84,34216.85,
SEIZURES WITHOUT MCC,101,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7060.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9178.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5110.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5110.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5257.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7201.85,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7060.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7060.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5012,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16057.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7060.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4913.72,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7060.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4913.72,16057.52,
HEADACHES WITH MCC,102,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8986.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11682.88,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6109.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6109.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6285.59,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9166.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8986.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8986.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5991.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20482.02,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8986.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5874.39,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8986.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5874.39,20482.02,
HEADACHES WITHOUT MCC,103,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6624.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8612.27,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4705.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4705.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4841.57,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6757.32,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6624.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6624.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4615.33,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14828.49,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6624.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4524.83,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6624.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4524.83,14828.49,
ORBITAL PROCEDURES WITH CC/MCC,113,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17422.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22649.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12094.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12094.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12443.47,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17770.93,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17422.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17422.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11862.01,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39993.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17422.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11629.41,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,17422.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11629.41,39993.28,
ORBITAL PROCEDURES WITHOUT CC/MCC,114,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9150.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11895.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7783.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7783.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8008.4,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9333.27,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9150.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9150.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7634.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23205.47,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9150.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7484.49,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9150.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7484.49,23205.47,
EXTRAOCULAR PROCEDURES EXCEPT ORBIT,115,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11307.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14699.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8393.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8393.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8635.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11533.48,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11307.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11307.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8231.8,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27058.21,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11307.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8070.38,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11307.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8070.38,27058.21,
INTRAOCULAR PROCEDURES WITH CC/MCC,116,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13035.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16945.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8573.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8573.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8820.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13295.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13035.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13035.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8408.53,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33602.34,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13035.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8243.65,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13035.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8243.65,33602.34,
INTRAOCULAR PROCEDURES WITHOUT CC/MCC,117,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8933.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11613.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6282.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6282.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6463.44,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9112.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8933.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8933.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6161.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17683.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8933.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6040.6,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8933.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6040.6,17683.75,
ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,121,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9470.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12311.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4181.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4181.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4302.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9660.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9470.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9470.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4101.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21825.04,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9470.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4021.07,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9470.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4021.07,21825.04,
ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,122,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5989.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7786.87,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3565.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3565.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3668.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6109.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5989.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5989.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3496.68,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12304.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5989.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3428.12,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5989.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3428.12,12304.53,
NEUROLOGICAL EYE DISORDERS,123,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6375.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8288.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5534.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5534.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5694.39,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6503.29,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6375.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6375.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5428.3,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14139.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6375.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5321.86,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6375.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5321.86,14139.17,
OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT,124,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9734.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12654.97,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5777.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5777.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5944.33,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9929.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9734.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9734.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5666.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24949.27,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9734.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5555.45,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9734.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5555.45,24949.27,
OTHER DISORDERS OF THE EYE WITHOUT MCC,125,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6333.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8233.71,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3602.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3602.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3706.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6460.29,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6333.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6333.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3533.34,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15355.73,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6333.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3464.05,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6333.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3464.05,15355.73,
SINUS AND MASTOID PROCEDURES WITH CC/MCC,135,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18361.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23870.05,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13564.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13564.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13955.47,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18728.81,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18361.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18361.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13303.36,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,43651.87,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18361.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13042.5,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,18361.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13042.5,43651.87,
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,136,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7934.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10314.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6912.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6912.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7111.63,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8092.91,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7934.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7934.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6779.32,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20667.26,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7934.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6646.39,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7934.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6646.39,20667.26,
MOUTH PROCEDURES WITH CC/MCC,137,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10920.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14196.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6176.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6176.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6354.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11138.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10920.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10920.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6057.99,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26710.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10920.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5939.2,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10920.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5939.2,26710.88,
MOUTH PROCEDURES WITHOUT CC/MCC,138,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6775.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8808.7,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4566.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4566.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4698.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6911.44,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6775.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6775.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4478.53,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15751.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6775.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4390.71,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6775.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4390.71,15751.15,
SALIVARY GLAND PROCEDURES,139,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8864.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11523.51,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6868.19,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6868.19,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7066.32,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9041.52,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8864.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8864.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6736.12,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22398.59,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8864.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6604.03,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8864.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6604.03,22398.59,
MAJOR HEAD AND NECK PROCEDURES WITH MCC,140,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25664.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33363.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4414.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4414.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4542.19,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,26177.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25664.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25664.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4329.94,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,74032.02,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,25664.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4245.04,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,25664.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4245.04,74032.02,
MAJOR HEAD AND NECK PROCEDURES WITH CC,141,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14597.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18976.62,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3707.4,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3707.4,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3814.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14889.35,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14597.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14597.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3636.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39767.07,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14597.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3564.8,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14597.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3564.8,39767.07,
MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,142,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11181.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14535.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8869.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8869.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9125.58,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11405.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11181.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11181.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8699.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30310.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11181.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8528.58,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11181.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8528.58,30310.68,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC",143,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22729.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29548.39,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15085.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15085.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15521.04,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23184.12,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22729.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22729.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14795.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,56510.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22729.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14505.64,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,22729.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14505.64,56510.35,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC",144,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12384.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16099.93,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4239.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4239.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4362.29,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12632.25,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12384.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12384.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4158.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32227.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12384.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4076.9,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12384.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4076.9,32227.25,
"OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC",145,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9080.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11805.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4681.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4681.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4816.16,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9262.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9080.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9080.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4591.11,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21513.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9080.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4501.09,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9080.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4501.09,21513.33,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC",146,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14852.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19307.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8995.19,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8995.19,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9254.67,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15149.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14852.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14852.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8822.21,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35876.93,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14852.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8649.22,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14852.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8649.22,35876.93,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC",147,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9176.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11929.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6720.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6720.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6914.57,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9359.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9176.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9176.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6591.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21572.11,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9176.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6462.21,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9176.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6462.21,21572.11,
"EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC",148,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6931.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9011.04,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5085.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5085.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5232.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7070.2,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6931.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6931.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4987.78,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14563.09,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6931.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4889.97,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6931.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4889.97,14563.09,
DYSEQUILIBRIUM,149,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7788.55,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4483.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4483.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4612.91,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6111.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4397.36,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13448.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4311.14,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4311.14,13448.06,
EPISTAXIS WITH MCC,150,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9686.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12592.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5563.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5563.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5723.91,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9880.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9686.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9686.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5456.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24568.09,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9686.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5349.45,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9686.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5349.45,24568.09,
EPISTAXIS WITHOUT MCC,151,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6159.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8007.74,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3405.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3405.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3503.97,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6283,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6159.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6159.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3340.24,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13733.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6159.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3274.74,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6159.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3274.74,13733.05,
OTITIS MEDIA AND URI WITH MCC,152,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8867.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11527.74,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5040.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5040.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5186.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9044.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8867.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8867.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4943.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21333.43,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8867.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4846.98,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8867.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4846.98,21333.43,
OTITIS MEDIA AND URI WITHOUT MCC,153,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5926.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7705.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4298.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4298.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4422.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6045.52,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5926.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5926.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4215.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12299.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5926.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4132.73,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5926.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4132.73,12299.19,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC",154,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11137.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14478.63,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7185.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7185.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7392.47,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11360.16,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11137.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11137.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7047.04,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26769.65,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11137.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6908.85,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11137.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6908.85,26769.65,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC",155,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7300.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9490.78,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4544.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4544.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4676.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7446.61,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7300.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7300.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4457.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16374.57,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7300.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4370.17,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7300.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4370.17,16374.57,
"OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC",156,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5412.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7036.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3603.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3603.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3707.91,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5520.94,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5412.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5412.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3534.65,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12142.44,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5412.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3465.34,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5412.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3465.34,12142.44,
DENTAL AND ORAL DISEASES WITH MCC,157,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12232.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15901.81,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6974.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6974.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7175.49,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12476.8,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12232.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12232.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6840.19,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29778.1,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12232.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6706.07,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12232.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6706.07,29778.1,
DENTAL AND ORAL DISEASES WITH CC,158,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7248.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9422.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6173.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6173.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6351.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7393.03,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7248.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7248.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6054.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16549.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7248.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5935.99,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7248.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5935.99,16549.13,
DENTAL AND ORAL DISEASES WITHOUT CC/MCC,159,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5540.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7202.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4820.62,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4820.62,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4959.67,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5651.25,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5540.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5540.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4727.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13357.22,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5540.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4635.21,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5540.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4635.21,13357.22,
MAJOR CHEST PROCEDURES WITH MCC,163,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31731.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41250.81,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,37987.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,37987.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,39083.43,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,32366.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31731.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31731.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37257.13,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,86275.98,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,31731.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36526.57,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,31731.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31731.39,86275.98,
MAJOR CHEST PROCEDURES WITH CC,164,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17702.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23012.61,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17618.64,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17618.64,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18126.87,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18056.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17702.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17702.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17279.84,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,46003.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17702.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16941,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,17702.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16941,46003.05,
MAJOR CHEST PROCEDURES WITHOUT CC/MCC,165,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13330.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17330.01,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12017.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12017.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12364.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13597.4,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13330.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13330.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11786.73,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34321.94,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13330.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11555.61,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13330.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11555.61,34321.94,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,166,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27478.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35721.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,27890.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,27890.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28695.1,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,28027.78,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27478.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27478.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27354.23,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,65295.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,27478.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26817.85,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,27478.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26817.85,65295.23,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,167,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12963.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16852.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12874.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12874.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13246.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13222.99,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12963.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12963.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12627.19,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33862.39,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12963.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12379.59,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12963.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12379.59,33862.39,
OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,168,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9953.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12939.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8906.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8906.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9163.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10152.88,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9953.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9953.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8735.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25250.29,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9953.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8563.87,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9953.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8563.87,25250.29,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM,173,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21104.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27435.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7849.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7849.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8075.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21526.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21104.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21104.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7698.33,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24879.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21104.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7547.37,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,21104.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7547.37,27435.58,
PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,175,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10260.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13338.75,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10571.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10571.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10876.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10465.79,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10260.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10260.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10368.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14563.09,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10260.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10164.99,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10260.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10164.99,14563.09,
PULMONARY EMBOLISM WITHOUT MCC,176,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6451,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8386.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6461.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6461.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6647.46,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6580.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6451,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6451,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6336.83,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31703.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6451,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6212.58,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6451,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6212.58,31703.58,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,177,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12163.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15812.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12776,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12776,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13144.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12406.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12163.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12163.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12530.32,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19361.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12163.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12284.62,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12163.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12163.41,19361.64,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,178,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7560.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9828.87,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9840.12,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9840.12,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10123.97,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7711.88,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7560.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7560.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9650.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13989.54,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7560.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9461.65,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7560.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7560.67,13989.54,
RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,179,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6111.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7945.37,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4853.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4853.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4994.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6234.06,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6111.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6111.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4760.64,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30171.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6111.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4667.3,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6111.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4667.3,30171.75,
RESPIRATORY NEOPLASMS WITH MCC,180,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12434.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16164.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11896.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11896.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12239.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12683.19,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12434.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12434.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11667.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20193.46,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12434.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11438.82,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12434.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11438.82,20193.46,
RESPIRATORY NEOPLASMS WITH CC,181,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8302.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10793.38,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8863.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8863.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9119.4,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8468.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8302.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8302.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8693.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15808.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8302.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8522.8,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8302.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8302.6,15808.15,
RESPIRATORY NEOPLASMS WITHOUT CC/MCC,182,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6342.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8244.67,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5056.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5056.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5202.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6468.89,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6342.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6342.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4958.98,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26757.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6342.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4861.74,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6342.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4861.74,26757.19,
MAJOR CHEST TRAUMA WITH MCC,183,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11372.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14784.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8761.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8761.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9014.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11600.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11372.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11372.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8593.12,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18617.1,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11372.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8424.62,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11372.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8424.62,18617.1,
MAJOR CHEST TRAUMA WITH CC,184,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7983.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10378.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5566.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5566.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5727.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8143.19,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7983.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7983.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5459.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13448.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7983.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5352.66,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7983.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5352.66,13448.06,
MAJOR CHEST TRAUMA WITHOUT CC/MCC,185,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6062.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7881.28,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3441.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3441.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3541.05,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6183.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6062.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6062.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3375.59,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27195.36,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6062.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3309.4,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6062.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3309.4,27195.36,
PLEURAL EFFUSION WITH MCC,186,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11227.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14595.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10871.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10871.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11185.53,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11452.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11227.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11227.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10662.85,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18629.57,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11227.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10453.77,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11227.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10453.77,18629.57,
PLEURAL EFFUSION WITH CC,187,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7622.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9909.81,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7745.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7745.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7969.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7775.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7622.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7622.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7596.87,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12895.89,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7622.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7447.91,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7622.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7447.91,12895.89,
PLEURAL EFFUSION WITHOUT CC/MCC,188,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6002.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7803.72,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4322.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4322.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4446.75,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6122.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6002.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6002.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4238.96,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21499.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6002.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4155.84,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6002.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4155.84,21499.08,
PULMONARY EDEMA AND RESPIRATORY FAILURE,189,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9151.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11897.03,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9362.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9362.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9633.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9334.59,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9151.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9151.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9182.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19334.93,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9151.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9002.82,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9151.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9002.82,19334.93,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,190,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8308.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10800.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7475.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7475.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7691.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8474.6,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8308.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8308.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7331.77,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15393.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8308.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7188.01,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8308.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7188.01,15393.13,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,191,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6667.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8667.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5984.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5984.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6157.19,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6800.97,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6667.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6667.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5869.48,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11615.21,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6667.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5754.38,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6667.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5754.38,11615.21,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,192,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5323.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6920.98,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4694.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4694.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4829.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5430.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5323.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5323.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4604.2,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23132.44,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5323.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4513.92,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5323.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4513.92,23132.44,
SIMPLE PNEUMONIA AND PLEURISY WITH MCC,193,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9765.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12694.6,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8968.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8968.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9227.2,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9960.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9765.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9765.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8796.03,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14965.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9765.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8623.55,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9765.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8623.55,14965.64,
SIMPLE PNEUMONIA AND PLEURISY WITH CC,194,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6493.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8441.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6207.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6207.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6386.53,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6623.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6493.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6493.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6088.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11431.74,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6493.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5968.72,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6493.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5968.72,11431.74,
SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,195,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5218.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6784.39,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4679.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4679.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4814.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5323.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5218.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5218.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4589.8,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30951.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5218.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4499.8,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5218.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4499.8,30951.91,
INTERSTITIAL LUNG DISEASE WITH MCC,196,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13454.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17490.23,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8674.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8674.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8925.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13723.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13454.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13454.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8508.02,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17519.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13454.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8341.19,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13454.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8341.19,17519.88,
INTERSTITIAL LUNG DISEASE WITH CC,197,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7630.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9919.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6821.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6821.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7018.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7783.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7630.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7630.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6690.3,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12662.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7630.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6559.11,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7630.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6559.11,12662.55,
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,198,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6208.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8070.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4526.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4526.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4657.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6332.62,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6208.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6208.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4439.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31324.18,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6208.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4352.85,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6208.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4352.85,31324.18,
PNEUMOTHORAX WITH MCC,199,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12667.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16467.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10105.74,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10105.74,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10397.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12920.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12667.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12667.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9911.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19094.46,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12667.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9717.06,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12667.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9717.06,19094.46,
PNEUMOTHORAX WITH CC,200,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8146.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10590.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5087.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5087.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5234.33,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8309.24,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8146.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8146.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4989.74,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12965.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8146.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4891.9,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8146.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4891.9,12965.35,
PNEUMOTHORAX WITHOUT CC/MCC,201,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5740.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7463.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4114.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4114.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4233.2,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5855.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5740.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5740.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4035.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16490.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5740.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3956.26,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5740.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3956.26,16490.35,
BRONCHITIS AND ASTHMA WITH CC/MCC,202,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7371.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9582.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5772.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5772.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5939.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7518.73,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7371.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7371.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5661.98,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11882.39,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7371.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5550.96,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7371.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5550.96,11882.39,
BRONCHITIS AND ASTHMA WITHOUT CC/MCC,203,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5668.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7368.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4138.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4138.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4257.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5781.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5668.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5668.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4058.95,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14417.03,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5668.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3979.36,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5668.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3979.36,14417.03,
RESPIRATORY SIGNS AND SYMPTOMS,204,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6498.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8447.86,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5319.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5319.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5473.29,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6628.32,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6498.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6498.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5217.53,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31723.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6498.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5115.22,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6498.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5115.22,31723.17,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,205,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12902.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16772.74,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7816.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7816.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8042.04,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13160.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12902.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12902.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7666.25,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15913.24,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12902.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7515.93,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12902.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7515.93,16772.74,
OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,206,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7085.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9211.71,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4587.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4587.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4719.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7227.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7085.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7085.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4498.82,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,116951.81,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7085.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4410.6,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7085.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4410.6,116951.81,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,207,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45963.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,59752.03,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,46627.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,46627.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,47972.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,46882.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45963.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45963.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45730.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,46312.98,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,45963.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44833.75,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,45963.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44833.75,59752.03,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,208,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18696.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24305.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14190.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14190.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14600.24,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19070.82,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18696.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18696.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13917.99,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,183520.6,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18696.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13645.08,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,18696.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13645.08,183520.6,
CONCOMITANT AORTIC AND MITRAL VALVE PROCEDURES,212,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,71014.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,92318.92,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3649.33,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3649.33,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3754.6,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,72434.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,71014.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,71014.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3579.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,173522.72,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,71014.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3508.97,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,71014.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3508.97,173522.72,
OTHER HEART ASSIST SYSTEM IMPLANT,215,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,67409.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,87632.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,85647.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,85647.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,88118.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,68757.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,67409.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,67409.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,84000.85,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,113084.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,67409.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,82353.72,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,67409.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,67409.28,113084.83,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,216,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,64104.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,83336.42,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,71665.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,71665.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,73732.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,65387.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,64104.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,64104.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,70287.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,105780.12,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,64104.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,68908.86,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,64104.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,64104.94,105780.12,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,217,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,42443.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,55176.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,41968.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,41968.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,43179.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,43292.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,42443.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42443.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41161.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,144781.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,42443.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40354.49,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,42443.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40354.49,144781.28,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,218,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38107.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,49539.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,33479.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,33479.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34445.11,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,38869.4,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38107.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38107.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32835.55,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,96810,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,38107.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32191.69,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,38107.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32191.69,96810,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,219,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,51172.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,66523.93,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,46381.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,46381.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,47719.43,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,52195.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,51172.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,51172.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45489.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,84279.26,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,51172.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44597.6,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,51172.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44597.6,84279.26,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,220,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,35175.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45727.72,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,37073.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,37073.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38142.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,35878.67,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,35175.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35175.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36360.38,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,136379.36,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,35175.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35647.4,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,35175.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35175.17,136379.36,
CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,221,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31309.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40702.77,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,36356.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,36356.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,37405.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,31936.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31309.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31309.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35657.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,92955.48,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,31309.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34958.19,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,31309.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31309.82,92955.48,
OTHER CARDIOTHORACIC PROCEDURES WITH MCC,228,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33839.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,43991.75,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,38091.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,38091.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,39189.86,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,34516.61,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33839.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33839.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37358.59,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,126272.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,33839.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36626.04,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,33839.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33839.81,126272.83,
OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,229,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21782.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28317.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,24372.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,24372.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25075.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22218.32,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21782.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21782.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23903.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,90087.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21782.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23434.66,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,21782.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21782.67,90087.75,
CORONARY BYPASS WITH PTCA WITH MCC,231,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,53792.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,69930.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,43924.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,43924.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45191.18,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,54868.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,53792.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53792.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,43079.48,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,114012.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,53792.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42234.75,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,53792.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42234.75,114012.83,
CORONARY BYPASS WITH PTCA WITHOUT MCC,232,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,39740.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,51663.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,37143.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,37143.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38214.82,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,40535.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,39740.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39740.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36429.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,89428.71,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,39740.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35714.79,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,39740.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35714.79,89428.71,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,233,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,51745.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,67269.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,43450.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,43450.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,44704.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,52780.48,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,51745.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,51745.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42615.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,87782.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,51745.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41779.77,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,51745.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41779.77,87782.88,
CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,234,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34872.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45333.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,30194.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,30194.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31065.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,35569.75,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34872.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34872.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29613.78,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,58795.63,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,34872.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29033.1,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,34872.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29033.1,58795.63,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,235,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,39299.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,51089.92,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,35838.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,35838.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,36872.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,40085.94,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,39299.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39299.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35149.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,149499.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,39299.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34460.21,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,39299.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34460.21,149499.68,
CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,236,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27370.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35581.72,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,25958.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,25958.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26707.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,27917.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27370.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27370.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25459.27,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,104339.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,27370.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24960.05,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,27370.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24960.05,104339.13,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,239,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32335.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42036.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,36974.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,36974.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38041.1,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,32982.54,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32335.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32335.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36263.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,137952.16,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,32335.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35552.43,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,32335.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32335.82,137952.16,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,240,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25194.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17934.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17934.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18452.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19768.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17590.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,92378.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17245.18,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,19380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17245.18,92378.38,
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,241,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10202.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13262.86,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7550.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7550.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7768.07,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10406.24,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10202.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10202.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7405.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,106693.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10202.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7259.88,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10202.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7259.88,106693.88,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,242,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23569.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30640.23,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,28390.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,28390.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29209.4,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24040.8,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23569.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23569.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27844.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,72644.46,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23569.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27298.51,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,23569.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23569.41,72644.46,
PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,243,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15932.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20712.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18223.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18223.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18748.98,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16251.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15932.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15932.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17872.87,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,82827.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15932.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17522.41,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15932.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15932.76,82827.58,
PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,244,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13026.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16934.61,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14122.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14122.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14529.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13287.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13026.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13026.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13850.57,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,48345.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13026.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13578.99,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13026.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13026.62,48345.33,
AICD GENERATOR PROCEDURES,245,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30549.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39714.65,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,33061.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,33061.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34015.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,31160.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30549.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30549.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32425.79,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27589.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,30549.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31789.97,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,30549.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27589.01,39714.65,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC,250,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16407.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21329.75,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16273.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16273.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16743.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16735.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16407.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16407.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15960.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,61869.98,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16407.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15647.92,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,16407.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15647.92,61869.98,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC,251,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11453.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14889.21,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9956.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9956.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10244.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11682.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11453.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11453.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9765.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41751.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11453.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9573.95,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11453.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9573.95,41751.33,
OTHER VASCULAR PROCEDURES WITH MCC,252,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22912.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29786.17,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,22688.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,22688.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23343.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23370.69,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22912.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22912.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22252.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33862.39,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22912.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21816.22,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,22912.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21816.22,33862.39,
OTHER VASCULAR PROCEDURES WITH CC,253,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17706.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23018.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19201.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19201.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19754.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18060.69,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17706.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17706.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18831.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,86851.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17706.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18462.54,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,17706.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17706.56,86851.31,
OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,254,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12414.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16138.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12623.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12623.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12987.98,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12662.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12414.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12414.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12381.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,53354.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12414.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12138.3,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12414.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12138.3,53354.06,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,255,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18979.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24673.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10082.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10082.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10373.22,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19359.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18979.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18979.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9888.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34012.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18979.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9694.6,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,18979.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9694.6,34012.01,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,256,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11795.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15334.38,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9852.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9852.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10136.33,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12031.59,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11795.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11795.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9662.67,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,53610.56,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11795.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9473.2,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11795.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9473.2,53610.56,
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,257,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7588.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9865.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5035.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5035.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5180.77,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7740.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7588.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7588.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4938.69,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32359.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7588.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4841.85,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7588.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4841.85,32359.06,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,258,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18728.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24346.41,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14215.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14215.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14625.65,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19102.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18728.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18728.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13942.21,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,43099.7,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18728.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13668.83,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,18728.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13668.83,43099.7,
CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,259,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13267.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17247.41,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9946.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9946.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10233.83,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13532.58,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13267.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13267.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9755.62,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28949.84,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13267.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13267.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9755.62,28949.84,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,260,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22662.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29460.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19017.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19017.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19566.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23115.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22662.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22662.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18651.8,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,59550.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22662.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,22662.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18651.8,59550.86,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,261,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13365.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17375.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9882.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9882.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10167.91,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13633.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13365.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13365.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9692.78,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,47629.29,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13365.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13365.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9692.78,47629.29,
CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,262,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11832,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15381.6,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9001.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9001.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9260.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12068.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11832,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11832,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8828.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32569.24,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11832,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11832,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8828.1,32569.24,
VEIN LIGATION AND STRIPPING,263,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19484.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25329.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17557.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17557.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18063.7,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19873.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19484.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19484.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17219.62,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,45698.47,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19484.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,19484.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17219.62,45698.47,
OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,264,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22343.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29045.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18288.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18288.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18816.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22789.87,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22343.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22343.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17937.02,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29072.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22343.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,22343.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17937.02,29072.75,
AICD LEAD PROCEDURES,265,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24081.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31306.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16700.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16700.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17182.73,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24563.41,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24081.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24081.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16379.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18679.44,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24081.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,24081.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16379.81,31306.3,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,266,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41670.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,54171.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,32171.25,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,32171.25,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33099.28,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,42503.79,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41670.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41670.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31552.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,50787.36,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,41670.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,41670.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31552.6,54171.49,
ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,267,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32811.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42655.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3673.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3673.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3779.32,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,33468.11,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32811.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32811.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3602.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35518.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,32811.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,32811.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3602.72,42655.43,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,268,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45617.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,59302.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17739.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17739.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18251.16,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,46529.78,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45617.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45617.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17398.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,62317.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,45617.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,45617.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17398.31,62317.06,
AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,269,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28131.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36571.52,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,2991.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,2991.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3077.57,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,28694.58,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28131.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28131.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2933.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34035.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,28131.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,28131.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2933.76,36571.52,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,270,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33957.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44145.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,1908.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,1908.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,1963.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,34637,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33957.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33957.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,1871.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29867.16,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,33957.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,33957.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,1871.4,44145.19,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,271,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23576.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30649.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3584.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3584.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3688,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24048.07,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23576.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23576.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3515.66,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,49624.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23576.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,23576.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3515.66,49624.23,
OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,272,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16982.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22077.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17322.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16982.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16982.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,58952.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16982.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16982.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16982.76,58952.38,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,273,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26435.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34365.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,25996.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,25996.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26746.39,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,26964.06,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26435.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26435.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25496.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,60241.97,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,26435.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,26435.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25496.58,60241.97,
PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,274,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22179.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28833.45,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13814.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13814.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14212.97,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22623.17,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22179.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22179.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13548.82,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,117571.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22179.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,22179.58,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13548.82,117571.67,
CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION AND MCC,275,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,46791.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,60829.55,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,33409.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,33409.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34373.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,47727.8,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,46791.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,46791.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32766.82,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,91920.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,46791.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,46791.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32766.82,91920.61,
CARDIAC DEFIBRILLATOR IMPLANT WITH MCC,276,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41437.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53868.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,23876.16,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,23876.16,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24564.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,42266.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41437.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41437.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23417.03,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,123273.29,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,41437.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,41437.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23417.03,123273.29,
CARDIAC DEFIBRILLATOR IMPLANT WITHOUT MCC,277,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32177.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41830.87,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,36040.16,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,36040.16,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,37079.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,32821.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32177.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32177.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35347.11,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,76169.46,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,32177.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,32177.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32177.59,76169.46,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC,278,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30089.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39116.04,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,23801.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,23801.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24488,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,30691.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30089.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30089.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23343.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,91065.63,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,30089.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,30089.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23343.72,91065.63,
ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC,279,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21918.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28494.52,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14997.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14997.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15429.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22357.24,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21918.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21918.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14708.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,62053.45,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21918.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,21918.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14708.71,62053.45,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC",280,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14885.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11104.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11104.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11425.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11679.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10891.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,46247.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10891.29,46247.08,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC",281,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7082.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9207.51,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6570.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6570.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6760.07,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7224.35,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7082.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7082.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6444.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,71479.56,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7082.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7082.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6444.18,71479.56,
"ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC",282,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5818.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7564.26,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6570.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6570.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6760.07,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5935.03,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5818.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5818.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6444.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,59839.41,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5818.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5818.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5818.66,59839.41,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC",283,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13946.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18131,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8311.11,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8311.11,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8550.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14225.86,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13946.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13946.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8151.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28613.2,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13946.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13946.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8151.29,28613.2,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC",284,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5958.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7746.39,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3948.33,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3948.33,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4062.22,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6077.94,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5958.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5958.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3872.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16362.1,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5958.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5958.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3872.4,16362.1,
"ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC",285,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4330.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5630.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3842.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3842.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3953.04,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,4417.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4330.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4330.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3768.32,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12765.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,4330.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,4330.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3768.32,12765.86,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC",286,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15141.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19684,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17198.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17198.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17694.97,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15444.37,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15141.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15141.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16868.11,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34174.1,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15141.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15141.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15141.54,34174.1,
"CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC",287,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8176.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10628.97,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8895.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8895.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9151.67,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8339.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8176.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8176.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8724.03,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13098.94,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8176.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8176.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8176.13,13098.94,
ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,288,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17978.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23371.78,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13988.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13988.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14392.18,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18337.86,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17978.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17978.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13719.66,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,9650.54,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17978.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17978.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9650.54,23371.78,
ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,289,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10745.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13968.55,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8953.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8953.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9212.1,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10959.94,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10745.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10745.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8781.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37779.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10745.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10745.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8781.63,37779.25,
ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,290,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8198.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10658.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8192.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8192.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8429.32,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8362.82,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8198.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8198.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8035.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19596.76,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8198.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8198.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8035.43,19596.76,
HEART FAILURE AND SHOCK WITH MCC,291,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9488.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12334.6,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9229.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9229.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9495.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9677.91,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9488.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9488.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9051.97,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,48030.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9488.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9488.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9051.97,48030.06,
HEART FAILURE AND SHOCK WITH CC,292,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6716.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8731.14,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5954.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5954.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6126.29,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6850.59,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6716.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6716.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5840.02,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28625.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6716.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6716.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5840.02,28625.67,
HEART FAILURE AND SHOCK WITHOUT CC/MCC,293,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4803.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6243.97,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4133.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4133.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4252.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,4899.11,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4803.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4803.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4053.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21475.93,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,4803.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,4803.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4053.71,21475.93,
DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,294,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8254.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10730.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5221.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5221.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5371.66,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8419.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8254.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8254.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5120.65,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22795.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8254.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8254.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5120.65,22795.8,
DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,295,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8230.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5221.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5221.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5371.66,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6457.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5120.65,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15368.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5120.65,15368.19,
"CARDIAC ARREST, UNEXPLAINED WITH MCC",296,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11558.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15026.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11473.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11473.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11804.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11790.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11558.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11558.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11253.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,9980.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11558.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11558.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9980.06,15026.66,
"CARDIAC ARREST, UNEXPLAINED WITH CC",297,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5886.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7652.79,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3230.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3230.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3323.39,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6004.5,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5886.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5886.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3168.09,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20563.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5886.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5886.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3168.09,20563.95,
"CARDIAC ARREST, UNEXPLAINED WITHOUT CC/MCC",298,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4013.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5217.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3230.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3230.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3323.39,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,4093.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4013.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4013.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3168.09,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15776.09,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,4013.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,4013.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3168.09,15776.09,
PERIPHERAL VASCULAR DISORDERS WITH MCC,299,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11383.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14799.01,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8367.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8367.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8609.22,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11611.53,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11383.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11383.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8206.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29181.4,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11383.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11383.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8206.92,29181.4,
PERIPHERAL VASCULAR DISORDERS WITH CC,300,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8081.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10505.9,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6894.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6894.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7093.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8243.09,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8081.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8081.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6761.65,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11333.78,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8081.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8081.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6761.65,11333.78,
PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,301,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5764.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7494.29,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3961.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3961.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4075.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5880.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5764.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5764.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3885.49,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,8701.16,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5764.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5764.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3885.49,8701.16,
ATHEROSCLEROSIS WITH MCC,302,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8432.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10962,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4955.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4955.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5098.38,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8600.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8432.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8432.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4860.14,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27394.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8432.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8432.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4860.14,27394.86,
ATHEROSCLEROSIS WITHOUT MCC,303,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5429.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7058.4,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4758.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4758.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4895.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5538.13,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5429.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5429.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4667.04,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18365.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5429.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5429.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4667.04,18365.95,
HYPERTENSION WITH MCC,304,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8613.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11197.25,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5897.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5897.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6067.24,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8785.54,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8613.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8613.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5783.73,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12756.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8613.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8613.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5783.73,12756.95,
HYPERTENSION WITHOUT MCC,305,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6048.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7862.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4825.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4825.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4965.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6169.22,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6048.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6048.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4733.15,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21477.71,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6048.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6048.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4733.15,21477.71,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,306,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11128.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14466.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5993.23,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5993.23,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6166.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11350.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11128.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11128.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5877.98,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12042.69,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11128.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11128.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5877.98,14466.83,
CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,307,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7274.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9457.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4655.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4655.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4789.38,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7420.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7274.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7274.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4565.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19568.26,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7274.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7274.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4565.58,19568.26,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,308,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8958.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11645.78,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8989.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8989.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9249.18,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9137.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8958.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8958.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8816.98,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13280.63,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8958.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8958.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8816.98,13280.63,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,309,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7788.55,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5752.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5752.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5918.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6111.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5642.34,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26286.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5991.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5642.34,26286.95,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,310,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4747.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6172.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3891.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3891.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4003.86,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,4842.88,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4747.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4747.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3816.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16233.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,4747.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,4747.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3816.76,16233.86,
ANGINA PECTORIS,311,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5688.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7395.65,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4878.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4878.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5018.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5802.74,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5688.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5688.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4784.21,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20886.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5688.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5688.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4784.21,20886.35,
SYNCOPE AND COLLAPSE,312,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6761.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8790.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5093.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5093.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5240.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6896.89,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6761.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6761.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4995.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13138.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6761.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6761.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4995.63,13138.13,
CHEST PAIN,313,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5854.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7610.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4990.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4990.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5134.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5971.43,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5854.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5854.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4894.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,9817.97,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5854.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5854.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4894.18,9817.97,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,314,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14738.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19160.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15563.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15563.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16012.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15033.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14738.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14738.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15264.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11900.2,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14738.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14738.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11900.2,19160.43,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,315,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7434.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9665.32,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7653.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7653.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7874.5,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7583.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7434.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7434.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7506.54,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15188.29,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7434.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7434.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7434.86,15188.29,
OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,316,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5653.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7350.12,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5863.76,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5863.76,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6032.91,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5767.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5653.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5653.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5751,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12885.2,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5653.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5653.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5653.94,12885.2,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,319,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29450.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38285.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,30039.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29450.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29450.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,37095.27,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,29450.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,29450.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29450.45,38285.59,
OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,320,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15598.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20277.56,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15910.08,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15598.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15598.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17250.92,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15598.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15598.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15598.12,20277.56,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITH MCC OR 4+ ARTERIES/INTRALUMINAL DEVICES,321,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19805.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25746.81,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20201.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19805.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19805.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12147.78,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19805.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,19805.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12147.78,25746.81,
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH INTRALUMINAL DEVICE WITHOUT MCC,322,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12987.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16883.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13246.81,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12987.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12987.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,76709.16,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12987.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12987.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12987.07,76709.16,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITH MCC,323,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28011.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36414.7,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,28571.54,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28011.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28011.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,44020.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,28011.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,28011.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28011.31,44020.58,
CORONARY INTRAVASCULAR LITHOTRIPSY WITH INTRALUMINAL DEVICE WITHOUT MCC,324,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20414.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26538.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20822.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20414.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20414.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,91176.07,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20414.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20414.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20414.23,91176.07,
CORONARY INTRAVASCULAR LITHOTRIPSY WITHOUT INTRALUMINAL DEVICE,325,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18310.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23804.27,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18677.2,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18310.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18310.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,45621.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18310.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18310.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18310.98,45621.88,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC",326,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34101.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44331.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,31206.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,31206.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32107.07,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,34783.2,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34101.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34101.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30606.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29526.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,34101.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,34101.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29526.95,44331.53,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC",327,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17358.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22565.75,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15610.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15610.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16060.74,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17705.44,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17358.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17358.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15310.25,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,82350.22,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17358.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17358.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15310.25,82350.22,
"STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC",328,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11520.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14976.92,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9491.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9491.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9765.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11751.12,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11520.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11520.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9309.21,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,43735.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11520.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11520.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9309.21,43735.58,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,329,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30455.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39591.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,32540.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,32540.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33479.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,31064.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30455.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30455.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31915.23,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30437.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,30455.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,30455.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30437.15,39591.57,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,330,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16545.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21509.35,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16862.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16862.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17348.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16876.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16545.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16545.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16538.21,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,72322.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16545.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16545.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16538.21,72322.06,
MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,331,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12005.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15606.72,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11251.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11251.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11576.23,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12245.27,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12005.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12005.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11035.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39775.98,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12005.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12005.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11035.29,39775.98,
RECTAL RESECTION WITH MCC,332,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24861.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32319.72,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,23878.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,23878.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24567.65,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25358.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24861.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24861.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23419.65,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30538.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24861.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,24861.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23419.65,32319.72,
RECTAL RESECTION WITH CC,333,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14647.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19042.39,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13141.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13141.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13520.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14940.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14647.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14647.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12888.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,65615.85,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14647.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14647.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12888.37,65615.85,
RECTAL RESECTION WITHOUT CC/MCC,334,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11571.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15042.68,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10177.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10177.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10471.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11802.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11571.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11571.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9982.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37886.12,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11571.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11571.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9982.1,37886.12,
PERITONEAL ADHESIOLYSIS WITH MCC,335,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24347.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31651.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,32356.12,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,32356.12,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33289.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24833.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24347.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24347.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31733.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28062.81,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24347.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,24347.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24347.02,33289.48,
PERITONEAL ADHESIOLYSIS WITH CC,336,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14815.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19259.93,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16442.68,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16442.68,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16917,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15111.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14815.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14815.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16126.49,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,47317.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14815.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14815.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14815.33,47317.58,
PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,337,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10866.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14126.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10053.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10053.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10343.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11083.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10866.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10866.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9859.7,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29005.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10866.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10866.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9859.7,29005.06,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,344,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18934.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24614.51,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17213.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17213.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17710.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19312.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18934.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18934.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16882.51,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21372.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18934.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18934.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16882.51,24614.51,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,345,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11152.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14498.86,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9053.25,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9053.25,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9314.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11376.03,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11152.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11152.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8879.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,40237.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11152.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11152.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8879.16,40237.31,
MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,346,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9513.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12367.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6451.74,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6451.74,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6637.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9703.71,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9513.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9513.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6327.67,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25884.4,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9513.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9513.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6327.67,25884.4,
ANAL AND STOMAL PROCEDURES WITH MCC,347,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17693.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23001.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7984.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7984.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8215.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18047.44,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17693.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17693.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7831.2,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19463.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17693.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17693.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7831.2,23001.64,
ANAL AND STOMAL PROCEDURES WITH CC,348,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9601.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12482.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7534.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7534.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7751.59,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9793.67,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9601.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9601.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7389.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,46890.09,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9601.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9601.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7389.37,46890.09,
ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,349,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7489.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9736.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5175.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5175.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5324.97,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7639.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7489.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7489.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5076.14,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27635.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7489.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7489.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5076.14,27635.32,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,350,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16726.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21744.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13466.76,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13466.76,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13855.22,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17061.13,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16726.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16726.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13207.79,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22277.47,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16726.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16726.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13207.79,22277.47,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,351,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10601.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13782.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8546.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8546.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8792.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10813.74,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10601.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10601.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8381.69,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,45210.42,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10601.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10601.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8381.69,45210.42,
INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,352,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8353.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10859.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5316.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5316.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5469.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8520.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8353.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8353.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5214.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24598.37,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8353.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8353.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5214.26,24598.37,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,353,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20126.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26165.01,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14896.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14896.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15326.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20529.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20126.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20126.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14610.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17762.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20126.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20126.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14610.52,26165.01,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,354,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12302.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15992.86,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10671.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10671.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10979.53,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12548.24,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12302.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12302.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10466.48,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41982.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12302.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12302.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10466.48,41982.88,
HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,355,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9998.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12998.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7540.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7540.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7757.77,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10198.53,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9998.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9998.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7395.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26187.2,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9998.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9998.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7395.26,26187.2,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,356,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28910.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37584.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,23665.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,23665.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24347.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,29489.07,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28910.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28910.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23210.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19630.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,28910.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,28910.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19630.61,37584.11,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,357,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15408.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20031.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10939.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10939.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11254.88,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15716.91,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15408.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15408.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10728.96,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,51081.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15408.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15408.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10728.96,51081.25,
OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,358,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9469.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12310.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10001.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10001.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10290.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9659.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9469.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9469.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9809.3,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31206.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9469.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9469.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9469.99,31206.62,
MAJOR ESOPHAGEAL DISORDERS WITH MCC,368,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11875.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15438.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9460.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9460.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9733.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12112.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11875.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11875.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9278.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24443.41,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11875.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11875.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9278.44,24443.41,
MAJOR ESOPHAGEAL DISORDERS WITH CC,369,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7571.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9842.37,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7697.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7697.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7919.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7722.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7571.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7571.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7549.09,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,75211.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7571.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7571.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7549.09,75211.17,
MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,370,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5984.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7780.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3882.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3882.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3994.93,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6104.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5984.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5984.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3808.25,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,40009.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5984.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5984.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3808.25,40009.31,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,371,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12496.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16244.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11455.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11455.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11786.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12746.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12496.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12496.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11235.59,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24708.81,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12496.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12496.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11235.59,24708.81,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,372,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7921.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10297.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6717.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6717.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6911.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8079.69,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7921.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7921.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6588.19,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31245.81,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7921.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7921.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6588.19,31245.81,
MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,373,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5808.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7550.79,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5270.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5270.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5422.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5924.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5808.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5808.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5169.09,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18205.65,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5808.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5808.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5169.09,18205.65,
DIGESTIVE MALIGNANCY WITH MCC,374,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14774.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19206.79,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11216.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11216.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11540.53,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15069.94,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14774.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14774.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11001.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13335.84,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14774.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14774.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11001.26,19206.79,
DIGESTIVE MALIGNANCY WITH CC,375,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8933,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11612.9,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8637.46,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8637.46,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8886.62,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9111.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8933,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8933,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8471.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30134.34,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8933,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8933,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8471.37,30134.34,
DIGESTIVE MALIGNANCY WITHOUT CC/MCC,376,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6942.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9025.39,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5377.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5377.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5533.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7081.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6942.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6942.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5274.48,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18132.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6942.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6942.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5274.48,18132.62,
GASTROINTESTINAL HEMORRHAGE WITH MCC,377,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12772.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16604.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10852.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10852.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11165.62,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13027.86,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12772.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12772.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10643.87,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12931.51,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12772.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12772.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10643.87,16604.13,
GASTROINTESTINAL HEMORRHAGE WITH CC,378,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9804.42,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6583.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6583.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6773.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7692.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6456.62,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35504.66,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7541.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6456.62,35504.66,
GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,379,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5268.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6848.48,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5293.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5293.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5445.82,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5373.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5268.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5268.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5191.35,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21456.34,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5268.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5268.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5191.35,21456.34,
COMPLICATED PEPTIC ULCER WITH MCC,380,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13798.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17937.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8487.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8487.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8732.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14074.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13798.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13798.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8324.09,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15635.37,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13798.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13798.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8324.09,17937.91,
COMPLICATED PEPTIC ULCER WITH CC,381,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8120.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10556.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6484.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6484.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6671.49,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8282.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8120.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8120.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6359.74,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31669.74,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8120.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8120.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6359.74,31669.74,
COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,382,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6071.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7893.08,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4861.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4861.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5002.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6193.03,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6071.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6071.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4768.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17544.82,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6071.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6071.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4768.5,17544.82,
UNCOMPLICATED PEPTIC ULCER WITH MCC,383,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10229.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13298.27,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7430.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7430.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7645.16,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10434.03,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10229.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10229.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7287.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11289.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10229.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10229.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7287.92,13298.27,
UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,384,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6840.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8893,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5330.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5330.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5484.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6977.59,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6840.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6840.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5228,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33915.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6840.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6840.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5228,33915.83,
INFLAMMATORY BOWEL DISEASE WITH MCC,385,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11323.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14720.62,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7490.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7490.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7706.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11550.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11323.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11323.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7346.17,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18800.57,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11323.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11323.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7346.17,18800.57,
INFLAMMATORY BOWEL DISEASE WITH CC,386,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7462.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9701.55,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7009.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7009.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7211.2,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7611.98,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7462.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7462.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6874.23,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13711.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7462.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7462.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6874.23,13711.68,
INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,387,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5598.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7277.6,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5654.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5654.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5817.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5710.11,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5598.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5598.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5545.47,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24224.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5598.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5598.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5545.47,24224.32,
GASTROINTESTINAL OBSTRUCTION WITH MCC,388,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10588.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13764.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8233.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8233.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8470.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10799.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10588.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10588.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8074.7,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16059.3,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10588.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10588.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8074.7,16059.3,
GASTROINTESTINAL OBSTRUCTION WITH CC,389,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6326.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8224.44,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5604.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5604.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5765.8,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6453.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6326.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6326.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5496.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29010.4,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6326.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6326.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5496.37,29010.4,
GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,390,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4786.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6222.88,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3926.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3926.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4039.56,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,4882.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4786.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4786.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3850.8,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17630.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,4786.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,4786.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3850.8,17630.32,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC",391,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9434.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12265.46,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7369.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7369.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7581.99,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9623.67,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9434.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9434.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7227.7,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12318.78,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9434.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9434.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7227.7,12318.78,
"ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC",392,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6256.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8133.37,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4970.11,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4970.11,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5113.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6381.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6256.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6256.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4874.54,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26137.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6256.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6256.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4874.54,26137.33,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,393,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11665.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15164.92,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8371.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8371.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8613.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11898.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11665.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11665.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8210.85,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14376.07,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11665.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11665.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8210.85,15164.92,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,394,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7237.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9409.01,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6624.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6624.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6815.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7382.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7237.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7237.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6497.2,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,10072.69,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7237.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7237.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6497.2,10072.69,
OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,395,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5360.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6969.03,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4482.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4482.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4612.23,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5468.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5360.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5360.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4396.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22870.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5360.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5360.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4396.71,22870.61,
APPENDIX PROCEDURES WITH MCC,397,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15731.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20451.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16046.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15731.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15731.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14028.73,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15731.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15731.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14028.73,20451.22,
APPENDIX PROCEDURES WITH CC,398,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10975.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14268.68,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11195.43,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10975.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10975.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,28700.48,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10975.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10975.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10975.91,28700.48,
APPENDIX PROCEDURES WITHOUT CC/MCC,399,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10894.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8548.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16796.72,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8380.44,16796.72,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH MCC",405,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,36865.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,47924.86,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,26019.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,26019.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26770.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,37602.59,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,36865.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36865.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25519.49,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11486.96,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,36865.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,36865.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11486.96,47924.86,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITH CC",406,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19887.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25853.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18683.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18683.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19222.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20285.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19887.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19887.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18323.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,98712.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19887.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,19887.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18323.86,98712.32,
"PANCREAS, LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC",407,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15111.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19645.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13745.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13745.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14141.56,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15413.94,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15111.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15111.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13480.75,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,52183.82,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15111.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15111.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13480.75,52183.82,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,408,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25301.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32892.18,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,20597.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,20597.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21192.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25807.71,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25301.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25301.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20201.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39644.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,25301.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,25301.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20201.81,39644.17,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,409,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13855.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18012.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13288.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13288.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13671.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14132.58,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13855.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13855.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13033.02,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,65361.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13855.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13855.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13033.02,65361.13,
BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,410,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11312.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14706.26,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9366.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9366.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9637.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11538.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11312.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11312.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9186.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37964.5,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11312.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11312.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9186.81,37964.5,
CHOLECYSTECTOMY WITH C.D.E. WITH MCC,411,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20879.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27143.87,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,24780.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,24780.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25495.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21297.5,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20879.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20879.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24303.96,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30239.43,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20879.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20879.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20879.9,30239.43,
CHOLECYSTECTOMY WITH C.D.E. WITH CC,412,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14561.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18929.42,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12656.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12656.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13021.63,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14852.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14561.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14561.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12413.15,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,60172.5,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14561.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14561.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12413.15,60172.5,
CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,413,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10951.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14237.48,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9343.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9343.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9613.1,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11170.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10951.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10951.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9163.9,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,40891.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10951.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10951.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9163.9,40891.01,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,414,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24024.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31231.25,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,24330.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,24330.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25032.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24504.52,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24024.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24024.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23862.79,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28862.56,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24024.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,24024.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23862.79,31231.25,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,415,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13975.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18168.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11768.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11768.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12108.39,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14254.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13975.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13975.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11542.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,62960.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13975.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13975.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11542.58,62960.08,
CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,416,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9846.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12800.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6264.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6264.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6444.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10043.74,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9846.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9846.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6143.74,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35624,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9846.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9846.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6143.74,35624,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,417,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16193.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21051.54,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14882.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14882.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15311.61,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16517.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16193.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16193.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14596.12,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24516.44,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16193.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16193.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14596.12,24516.44,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,418,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11763.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15292.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10095.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10095.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10386.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11998.53,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11763.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11763.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9901.59,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,42351.59,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11763.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11763.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9901.59,42351.59,
LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,419,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9678.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12581.63,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7932.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7932.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8160.84,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9871.74,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9678.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9678.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7779.49,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29585.73,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9678.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9678.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7779.49,29585.73,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,420,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21920.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28496.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,22788.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,22788.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23446.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22358.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21920.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21920.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22350.74,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23244.66,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21920.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,21920.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21920.17,28496.22,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,421,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12249.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15923.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9088.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9088.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9350.8,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12494,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12249.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12249.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8913.85,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,58088.49,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12249.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12249.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8913.85,58088.49,
HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,422,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10312.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13406.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8058.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8058.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8291.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10518.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10312.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10312.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7903.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32268.22,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10312.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10312.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7903.86,32268.22,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,423,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26525.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34483.15,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,21504.23,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,21504.23,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22124.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,27056.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26525.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26525.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21090.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24680.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,26525.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,26525.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21090.71,34483.15,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,424,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19482.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12245.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12245.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12598.65,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15286.27,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12009.94,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,70035,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12009.94,70035,
OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,425,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11550.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15015.7,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12035.19,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12035.19,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12382.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11781.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11550.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11550.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11803.75,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,42189.5,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11550.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11550.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11550.54,42189.5,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,432,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13587.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17663.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12505.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12505.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12865.76,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13859.37,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13587.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13587.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12264.57,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25481.85,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13587.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13587.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12264.57,25481.85,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,433,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7847.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10202.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6292.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6292.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6474.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8004.93,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7847.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7847.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6171.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33632.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7847.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7847.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6171.88,33632.62,
CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,434,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5503.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7154.51,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4378.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4378.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4504.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5613.54,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5503.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5503.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4293.94,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18520.92,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5503.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5503.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4293.94,18520.92,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,435,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12575.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16347.8,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9547.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9547.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9823.21,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12826.73,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12575.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12575.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9364.19,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11180.59,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12575.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12575.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9364.19,16347.8,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,436,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8300.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10790.01,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7029.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7029.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7232.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8466.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8300.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8300.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6894.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31138.94,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8300.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8300.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6894.52,31138.94,
MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,437,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6551.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8516.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5521.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5521.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5680.66,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6682.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6551.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6551.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5415.21,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19600.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6551.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6551.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5415.21,19600.32,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,438,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11984.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15579.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11810.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11810.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12150.96,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12224.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11984.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11984.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11583.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15067.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11984.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11984.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11583.16,15579.73,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,439,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6707.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8720.18,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5997.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5997.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6170.24,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6841.99,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6707.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6707.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5881.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29521.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6707.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6707.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5881.91,29521.61,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,440,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5153.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6700.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4391.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4391.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4518.16,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5256.98,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5153.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5153.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4307.03,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15492.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5153.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5153.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4307.03,15492.88,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC",441,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13018.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16923.63,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12131.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12131.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12481.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13278.54,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13018.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13018.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11898.66,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,10801.2,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13018.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13018.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10801.2,16923.63,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC",442,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7332.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9532.08,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7309.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7309.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7520.19,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7479.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7332.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7332.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7168.78,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33750.18,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7332.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7332.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7168.78,33750.18,
"DISORDERS OF LIVER EXCEPT MALIGNANCY, CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC",443,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5796.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7535.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4546.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4546.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4678.15,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5912.54,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5796.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5796.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4459.54,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16850.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5796.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5796.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4459.54,16850.15,
DISORDERS OF THE BILIARY TRACT WITH MCC,444,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11753.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15279.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10198.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10198.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10492.7,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11988.6,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11753.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11753.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10002.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11611.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11753.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11753.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10002.39,15279.59,
DISORDERS OF THE BILIARY TRACT WITH CC,445,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8209.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10672.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7408.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7408.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7622.5,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8374.07,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8209.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8209.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7266.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29651.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8209.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8209.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7266.31,29651.64,
DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,446,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6359.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8267.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4701.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4701.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4837.45,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6486.75,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6359.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6359.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4611.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19586.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6359.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6359.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4611.4,19586.08,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,453,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,58631.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,76221.38,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,60934.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,60934.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,62691.83,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,59804.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,58631.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,58631.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,59762.35,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14458,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,58631.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,58631.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14458,76221.38,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,454,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40828.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53077.12,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,35593,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,35593,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,36619.73,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,41645.12,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40828.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40828.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34908.55,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,163065.3,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,40828.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,40828.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34908.55,163065.3,
COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,455,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31030.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40340.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,32760.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,32760.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33705.59,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,31651.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31030.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31030.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32130.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,108491.11,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,31030.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,31030.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31030.95,108491.11,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC",456,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,55830.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,72579.14,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,74795.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,74795.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,76952.87,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,56946.71,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,55830.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,55830.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,73356.99,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,85283.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,55830.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,55830.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,55830.11,85283.86,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC",457,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40562.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,52731.45,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,52472.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,52472.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,53986.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,41373.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40562.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40562.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,51463.79,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,150497.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,40562.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,40562.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40562.65,150497.15,
"SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC",458,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30547.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39711.28,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,50353.18,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,50353.18,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,51805.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,31158.08,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30547.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30547.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,49384.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,107527.48,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,30547.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,30547.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30547.14,107527.48,
SPINAL FUSION EXCEPT CERVICAL WITH MCC,459,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,44175.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,57427.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,60056.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,60056.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,61788.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,45058.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,44175.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44175.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,58901.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,85730.94,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,44175.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,44175.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,44175.06,85730.94,
SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,460,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24884.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32350.08,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,26820.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,26820.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27594.4,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25382.37,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24884.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24884.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26304.96,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,118147,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24884.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,24884.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24884.68,118147,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,461,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45382.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,58997.46,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,26661.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,26661.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27430.29,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,46290.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45382.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45382.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26148.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,67079.99,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,45382.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,45382.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26148.52,67079.99,
BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,462,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19621.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25507.37,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,26661.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,26661.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27430.29,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20013.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19621.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19621.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26148.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,114267.54,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19621.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,19621.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19621.05,114267.54,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,463,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,37893.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,49261.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,38553.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,38553.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,39665.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,38651.09,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,37893.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37893.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37812.2,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,53179.51,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,37893.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,37893.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37812.2,53179.51,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,464,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20626.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26815.05,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,20095.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,20095.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20675.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21039.5,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20626.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20626.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19708.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,93363.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20626.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20626.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19708.92,93363.38,
WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,465,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13294.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17282.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9793.4,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9793.4,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10075.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13560.37,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13294.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13294.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9605.07,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,53208.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13294.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13294.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9605.07,53208.01,
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,466,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34799.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45238.71,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,21673.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,21673.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22298.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,35494.99,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34799.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34799.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21256.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35493.97,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,34799.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,34799.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21256.31,45238.71,
REVISION OF HIP OR KNEE REPLACEMENT WITH CC,467,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23771.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30903.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19647.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19647.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20214.29,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24247.21,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23771.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23771.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19269.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,93425.72,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23771.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,23771.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19269.71,93425.72,
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,468,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18475.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24017.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15771.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15771.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16226.23,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18844.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18475.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18475.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15468,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,64584.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18475.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18475.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15468,64584.53,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,469,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22756.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29583.8,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19221.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19221.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19775.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23211.91,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22756.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22756.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18851.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,49683.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22756.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,22756.77,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18851.44,49683.01,
MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,470,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13365.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17374.72,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14469.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14469.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14887.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13632.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13365.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13365.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14191.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,57557.7,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13365.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13365.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13365.17,57557.7,
CERVICAL SPINAL FUSION WITH MCC,471,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33063.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42982.54,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,22564.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,22564.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23215.64,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,33724.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33063.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33063.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22130.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34054.76,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,33063.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,33063.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22130.81,42982.54,
CERVICAL SPINAL FUSION WITH CC,472,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20328.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26427.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17431.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17431.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17933.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20735.2,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20328.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20328.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17095.9,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,89719.04,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20328.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20328.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17095.9,89719.04,
CERVICAL SPINAL FUSION WITHOUT CC/MCC,473,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17119.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22255.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13516.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13516.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13906.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17462,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17119.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17119.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13256.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,54700.65,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17119.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17119.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13256.88,54700.65,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,474,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29067.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37787.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,23324.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,23324.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23997.73,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,29648.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29067.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29067.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22876.36,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,45155.2,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,29067.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,29067.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22876.36,45155.2,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,475,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15070.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19592.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14768.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14768.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15194.88,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15372.27,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15070.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15070.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14484.85,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,72973.98,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15070.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15070.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14484.85,72973.98,
AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,476,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8794.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11432.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6401.68,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6401.68,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6586.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8970.09,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8794.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8794.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6278.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39564.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8794.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8794.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6278.58,39564.01,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,477,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23011.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29914.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18776.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18776.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19318.21,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23471.24,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23011.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23011.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18415.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21864.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23011.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,23011.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18415.5,29914.33,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,478,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16620.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21607.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15023.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15023.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15457.18,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16953.29,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16620.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16620.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14734.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,60610.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16620.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16620.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14734.89,60610.67,
BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,479,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13250.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17225.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11291.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11291.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11616.74,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13515.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13250.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13250.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11073.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41838.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13250.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13250.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11073.91,41838.61,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,480,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20286.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26372.4,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,25679.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,25679.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26420.23,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20692.19,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20286.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20286.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25185.66,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31498.74,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20286.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20286.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20286.46,31498.74,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,481,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14618.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19003.6,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15615.78,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15615.78,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16066.24,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14910.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14618.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14618.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15315.49,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,52830.39,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14618.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14618.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14618.15,52830.39,
HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,482,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11462.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14901.86,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11067.46,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11067.46,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11386.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11692.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11462.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11462.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10854.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37626.07,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11462.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11462.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10854.63,37626.07,
MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,483,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17272.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22454.46,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15412.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15412.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15856.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17618.11,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17272.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17272.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15115.85,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29320.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17272.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17272.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15115.85,29320.33,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,485,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22524.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29281.98,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13576.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13576.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13968.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22975.09,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22524.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22524.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13315.8,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41993.57,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22524.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,22524.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13315.8,41993.57,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,486,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14186.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18442.1,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12593.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12593.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12957.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14469.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14186.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14186.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12351.62,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,57906.81,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14186.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14186.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12351.62,57906.81,
KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,487,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11180.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14535.12,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6908.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6908.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7108.2,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11404.48,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11180.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11180.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6776.05,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37155.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11180.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11180.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6776.05,37155.83,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,488,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14823.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19270.88,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10086.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10086.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10377.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15120.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14823.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14823.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9892.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28570.45,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14823.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14823.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9892.43,28570.45,
KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,489,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9188.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11945.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9009.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9009.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9269.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9372.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9188.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9188.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8835.96,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,40418.99,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9188.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9188.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8835.96,40418.99,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH MCC",492,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23614.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30699.25,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,21204.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,21204.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21816.24,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24087.11,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23614.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23614.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20796.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23681.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23614.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,23614.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20796.81,30699.25,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITH CC",493,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16737.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21758.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14285.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14285.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14697.74,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17072.37,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16737.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16737.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14010.94,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,62090.85,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16737.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16737.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14010.94,62090.85,
"LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP, FOOT AND FEMUR WITHOUT CC/MCC",494,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13284.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17269.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10456.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10456.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10758.43,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13549.79,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13284.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13284.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10255.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,42317.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13284.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13284.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10255.71,42317.75,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,495,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24387.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31703.4,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17119.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17119.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17613.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24874.97,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24387.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24387.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16790.22,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33643.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24387.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,24387.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16790.22,33643.31,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,496,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14051.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18266.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9599.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9599.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9876.77,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14332.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14051.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14051.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9415.25,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,66160.89,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14051.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14051.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9415.25,66160.89,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,497,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10418.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13544.45,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7643.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7643.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7863.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10627.19,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10418.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10418.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7496.07,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37399.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10418.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10418.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7496.07,37399.86,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,498,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18095.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23523.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12414.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12414.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12772.38,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18456.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18095.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18095.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12175.54,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27104.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18095.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18095.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12175.54,27104.52,
LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,499,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9526.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12384.35,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6661.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6661.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6853.45,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9716.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9526.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9526.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6533.2,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,45653.94,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9526.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9526.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6533.2,45653.94,
SOFT TISSUE PROCEDURES WITH MCC,500,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22192.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28850.32,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15481.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15481.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15928.22,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22636.4,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22192.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22192.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15183.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23488.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22192.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,22192.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15183.92,28850.32,
SOFT TISSUE PROCEDURES WITH CC,501,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12418.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16143.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11845.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11845.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12187.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12666.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12418.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12418.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11617.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,57078.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12418.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12418.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11617.86,57078.55,
SOFT TISSUE PROCEDURES WITHOUT CC/MCC,502,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10128.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13167.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8805.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8805.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9059.66,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10331.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10128.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10128.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8636.32,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31309.93,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10128.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10128.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8636.32,31309.93,
FOOT PROCEDURES WITH MCC,503,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18554.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24121.31,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11489.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11489.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11821.37,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18925.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18554.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18554.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11268.97,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24482.59,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18554.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18554.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11268.97,24482.59,
FOOT PROCEDURES WITH CC,504,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12362.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16071.26,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10010.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10010.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10299.75,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12609.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12362.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12362.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9818.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,45123.14,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12362.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12362.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9818.46,45123.14,
FOOT PROCEDURES WITHOUT CC/MCC,505,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12223.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15890.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9655.25,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9655.25,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9933.77,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12468.19,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12223.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12223.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9469.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31612.74,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12223.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12223.72,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9469.58,31612.74,
MAJOR THUMB OR JOINT PROCEDURES,506,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10647.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13841.23,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7035.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7035.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7237.98,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10860.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10647.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10647.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6899.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31470.24,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10647.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10647.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6899.76,31470.24,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,507,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19482.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9986.94,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9986.94,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10275.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15286.27,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9794.9,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25111.36,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14986.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9794.9,25111.36,
MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,508,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10461.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13600.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8417.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8417.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8660.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10670.85,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10461.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10461.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8256.02,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33037.7,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10461.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10461.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8256.02,33037.7,
ARTHROSCOPY,509,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10021.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13027.63,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13757.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13757.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14153.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10221.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10021.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10021.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13492.53,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25795.34,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10021.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10021.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10021.25,25795.34,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC",510,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18805.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24447.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14252.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14252.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14663.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19181.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18805.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18805.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13978.21,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27036.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18805.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18805.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13978.21,27036.83,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC",511,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14092.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18319.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10467.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10467.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10769.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14374.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14092.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14092.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10266.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,51442.84,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14092.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14092.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10266.18,51442.84,
"SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC",512,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11627.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15116.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6896.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6896.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7095.15,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11860.26,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11627.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11627.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6763.61,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35249.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11627.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11627.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6763.61,35249.95,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC",513,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15176.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8842.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8842.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9097.43,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11907.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8672.32,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28614.98,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8672.32,28614.98,
"HAND OR WRIST PROCEDURES, EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC",514,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7916.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10290.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7265.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7265.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7474.87,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8074.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7916.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7916.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7125.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28392.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7916.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7916.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7125.58,28392.33,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,515,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21665.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28164.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,24311.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,24311.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25012.6,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22098.58,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21665.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21665.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23843.8,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18394.45,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21665.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,21665.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18394.45,28164.85,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,516,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14397.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18716.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14522.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14522.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14941.5,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14684.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14397.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14397.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14243.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,55534.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14397.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14397.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14243.31,55534.25,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,517,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10853.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14109.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13401.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13401.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13787.93,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11070.41,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10853.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10853.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13143.65,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36226.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10853.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10853.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10853.34,36226.05,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,518,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24845.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32298.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15754.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15754.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16209.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25342.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24845.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24845.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15451.64,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26894.34,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24845.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,24845.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15451.64,32298.64,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,519,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13928.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18107.38,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13363.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13363.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13748.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14207.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13928.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13928.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13106.33,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,66397.79,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13928.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13928.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13106.33,66397.79,
BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,520,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10445.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13579.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7273.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7273.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7483.11,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10654.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10445.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10445.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7133.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35611.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10445.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10445.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7133.44,35611.53,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,521,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20580.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26754.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20991.87,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20580.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20580.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,26358.2,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20580.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20580.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20580.26,26754.34,
HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,522,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14860.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19318.1,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15157.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14860.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14860.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,53777.99,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14860.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14860.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14860.08,53777.99,
FRACTURES OF FEMUR WITH MCC,533,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11741.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15264.41,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6070.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6070.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6245.77,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11976.69,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11741.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11741.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5953.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,38703.69,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11741.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11741.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5953.91,38703.69,
FRACTURES OF FEMUR WITHOUT MCC,534,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6414.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8339.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3200.17,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3200.17,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3292.49,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6542.99,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6414.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6414.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3138.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25405.26,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6414.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6414.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3138.63,25405.26,
FRACTURES OF HIP AND PELVIS WITH MCC,535,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9571.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12442.52,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5694.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5694.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5859.18,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9762.59,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9571.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9571.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5585.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14176.57,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9571.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9571.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5585.39,14176.57,
FRACTURES OF HIP AND PELVIS WITHOUT MCC,536,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6266.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8146.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4859.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4859.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4999.5,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6391.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6266.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6266.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4765.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22968.57,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6266.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6266.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4765.88,22968.57,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC",537,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7432.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9662.78,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4573.68,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4573.68,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4705.61,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7581.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7432.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7432.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4485.73,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13841.71,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7432.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7432.91,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4485.73,13841.71,
"SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC",538,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5760.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7488.39,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3437.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3437.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3536.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5875.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5760.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5760.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3371,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17694.44,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5760.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5760.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3371,17694.44,
OSTEOMYELITIS WITH MCC,539,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14031.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18240.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12003.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12003.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12349.4,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14311.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14031.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14031.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11772.33,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12400.71,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14031.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14031.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11772.33,18240.59,
OSTEOMYELITIS WITH CC,540,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9580.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12455.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8662.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8662.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8912.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9772.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9580.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9580.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8496.24,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35550.97,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9580.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9580.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8496.24,35550.97,
OSTEOMYELITIS WITHOUT CC/MCC,541,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6725.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8742.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4852.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4852.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4992.63,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6859.85,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6725.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6725.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4759.33,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23985.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6725.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6725.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4759.33,23985.64,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,542,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12989.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16885.71,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9812.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9812.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10095.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13248.79,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12989.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12989.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9624.05,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14570.22,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12989.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12989.01,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9624.05,16885.71,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,543,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8235.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10705.71,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9569.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9569.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9845.87,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8399.86,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8235.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8235.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9385.79,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32560.34,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8235.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8235.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8235.16,32560.34,
PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,544,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6139.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7980.78,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4211.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4211.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4332.76,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6261.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6139.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6139.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4130.3,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19397.27,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6139.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6139.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4130.3,19397.27,
CONNECTIVE TISSUE DISORDERS WITH MCC,545,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22530.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15156.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15156.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15593.82,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17677.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14865.15,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13859.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17331.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13859.52,22530.33,
CONNECTIVE TISSUE DISORDERS WITH CC,546,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8939.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11621.32,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7933.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7933.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8162.21,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9118.27,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8939.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8939.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7780.8,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,44683.18,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8939.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8939.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7780.8,44683.18,
CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,547,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6500.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8451.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5353.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5353.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5508.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6630.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6500.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6500.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5250.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21474.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6500.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6500.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5250.91,21474.15,
SEPTIC ARTHRITIS WITH MCC,548,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13806.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17948.88,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8946.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8946.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9204.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14082.97,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13806.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13806.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8774.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16294.42,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13806.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13806.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8774.43,17948.88,
SEPTIC ARTHRITIS WITH CC,549,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8984.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11679.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8946.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8946.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9204.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9163.91,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8984.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8984.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8774.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34553.5,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8984.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8984.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8774.43,34553.5,
SEPTIC ARTHRITIS WITHOUT CC/MCC,550,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7280.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9464.65,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5048.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5048.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5194.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7426.11,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7280.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7280.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4951.78,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21582.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7280.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7280.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4951.78,21582.8,
MEDICAL BACK PROBLEMS WITH MCC,551,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12199.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15858.8,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7402.11,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7402.11,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7615.64,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12443.06,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12199.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12199.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7259.77,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18672.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12199.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12199.08,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7259.77,18672.32,
MEDICAL BACK PROBLEMS WITHOUT MCC,552,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7428.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9656.88,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6018.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6018.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6192.21,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7576.94,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7428.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7428.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5902.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29806.6,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7428.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7428.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5902.86,29806.6,
BONE DISEASES AND ARTHROPATHIES WITH MCC,553,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9926.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12904.54,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5680.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5680.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5844.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10125.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9926.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9926.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5570.99,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17108.43,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9926.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9926.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5570.99,17108.43,
BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,554,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6491.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8438.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5317.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5317.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5471.23,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6621.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6491.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6491.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5215.57,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23616.93,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6491.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6491.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5215.57,23616.93,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,555,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10234.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13305.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7628.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7628.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7848.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10439.32,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10234.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10234.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7481.67,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14609.4,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10234.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10234.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7481.67,14609.4,
SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,556,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6508.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8460.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5049.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5049.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5195.19,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6638.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6508.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6508.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4952.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23711.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6508.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6508.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4952.43,23711.33,
"TENDONITIS, MYOSITIS AND BURSITIS WITH MCC",557,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11258.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14635.45,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6619.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6619.92,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6810.88,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11483.2,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11258.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11258.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6492.62,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14392.1,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11258.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11258.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6492.62,14635.45,
"TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC",558,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6858.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8915.78,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5201.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5201.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5351.75,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6995.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6858.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6858.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5101.67,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25505,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6858.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6858.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5101.67,25505,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC",559,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13162.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17111.67,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19329.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19329.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19887.44,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13426.08,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13162.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13162.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18958.14,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15478.63,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13162.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13162.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13162.82,19887.44,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC",560,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8503.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11054.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13527.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13527.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13917.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8673.73,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8503.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8503.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13267.36,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31794.42,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8503.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8503.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8503.66,31794.42,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC",561,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6221.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8087.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10003.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10003.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10292.2,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6345.85,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6221.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6221.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9811.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19514.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6221.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6221.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6221.42,19514.83,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC",562,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11023.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14331.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6459.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6459.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6646.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11244.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11023.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11023.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6335.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14075.04,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11023.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11023.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6335.52,14331.07,
"FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC",563,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6969.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9060.79,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5716.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5716.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5881.16,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7109.24,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6969.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6969.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5606.34,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26055.39,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6969.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6969.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5606.34,26055.39,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,564,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11291.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14678.44,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7568.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7568.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7787.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11516.93,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11291.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11291.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7423.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15339.69,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11291.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11291.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7423.41,15339.69,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,565,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7643.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9935.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7568.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7568.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7787.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7795.89,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7643.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7643.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7423.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27667.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7643.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7643.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7423.41,27667.38,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,566,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6028.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7837.44,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3874.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3874.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3986.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6149.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6028.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6028.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3800.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17587.57,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6028.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6028.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3800.4,17587.57,
SKIN DEBRIDEMENT WITH MCC,570,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20113.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26147.28,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10943.33,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10943.33,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11259,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20515.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20113.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20113.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10732.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13228.97,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20113.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20113.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10732.89,26147.28,
SKIN DEBRIDEMENT WITH CC,571,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12134.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15774.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8132.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8132.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8366.83,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12376.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12134.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12134.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7975.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,51959.39,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12134.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12134.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7975.86,51959.39,
SKIN DEBRIDEMENT WITHOUT CC/MCC,572,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8552.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11117.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6063.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6063.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6238.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8723.35,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8552.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8552.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5947.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29364.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8552.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8552.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5947.37,29364.86,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,573,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41488.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53935.41,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18501.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18501.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19035.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,42318.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41488.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41488.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18145.82,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21438.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,41488.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,41488.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18145.82,53935.41,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,574,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23249.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30224.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14571.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14571.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14991.63,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23714.67,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23249.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23249.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14291.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,104565.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23249.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,23249.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14291.1,104565.35,
SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,575,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14430.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18759.95,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9571.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9571.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9847.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14719.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14430.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14430.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9387.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,64205.14,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14430.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14430.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9387.1,64205.14,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,576,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38019.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,49424.75,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,34049.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,34049.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,35031.51,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,38779.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38019.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38019.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33394.55,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36507.48,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,38019.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,38019.04,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33394.55,49424.75,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,577,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18342.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23844.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15173.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15173.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15610.99,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18708.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18342.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18342.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14881.51,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,100619.99,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18342.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18342.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14881.51,100619.99,
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,578,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11606.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15088.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10006.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10006.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10294.94,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11838.44,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11606.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11606.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9813.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,46644.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11606.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11606.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9813.88,46644.28,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC",579,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22837.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29688.37,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,20457.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,20457.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21047.2,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23293.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22837.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22837.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20063.7,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30503.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22837.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,22837.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20063.7,30503.05,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC",580,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12488.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16235.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9203.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9203.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9468.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12738.75,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12488.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12488.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9026.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,56138.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12488.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12488.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9026.44,56138.08,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC",581,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9895.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12864.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6563.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6563.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6753.2,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10093.35,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9895.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9895.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6437.64,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30925.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9895.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9895.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6437.64,30925.19,
MASTECTOMY FOR MALIGNANCY WITH CC/MCC,582,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12454.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16190.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10257.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10257.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10553.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12703.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12454.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12454.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10059.99,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25141.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12454.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12454.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10059.99,25141.64,
MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,583,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11031.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14341.21,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9619.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9619.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9897.37,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11252.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11031.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11031.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9434.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34462.66,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11031.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11031.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9434.89,34462.66,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC",584,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13863.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18023.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11421.18,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11421.18,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11750.64,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14141.18,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13863.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13863.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11201.55,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26910.37,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13863.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13863.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11201.55,26910.37,
"BREAST BIOPSY, LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC",585,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12082.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15707.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10242.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10242.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10538.02,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12324.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12082.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12082.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10045.59,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,38042.87,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12082.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12082.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10045.59,38042.87,
SKIN ULCERS WITH MCC,592,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14716.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19131.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9630.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9630.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9908.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15011.07,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14716.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14716.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9445.36,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32793.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14716.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14716.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9445.36,32793.67,
SKIN ULCERS WITH CC,593,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9008.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11710.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6770.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6770.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6966.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9188.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9008.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9008.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6640.55,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31776.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9008.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9008.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6640.55,31776.61,
SKIN ULCERS WITHOUT CC/MCC,594,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6268.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8148.56,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3357.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3357.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3453.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6393.48,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6268.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6268.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3292.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20517.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6268.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6268.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3292.46,20517.64,
MAJOR SKIN DISORDERS WITH MCC,595,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15267.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19847.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9931.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9931.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10218.04,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15572.71,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15267.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15267.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9740.57,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13784.71,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15267.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15267.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9740.57,19847.57,
MAJOR SKIN DISORDERS WITHOUT MCC,596,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7705.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10016.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5993.23,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5993.23,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6166.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7859.41,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7705.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7705.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5877.98,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,38142.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7705.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7705.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5877.98,38142.62,
MALIGNANT BREAST DISORDERS WITH MCC,597,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11541.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15003.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8198.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8198.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8434.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11772.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11541.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11541.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8040.66,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19447.14,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11541.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11541.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8040.66,19447.14,
MALIGNANT BREAST DISORDERS WITH CC,598,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8936.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11617.1,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6202.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6202.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6381.73,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9114.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8936.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8936.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6083.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29995.41,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8936.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8936.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6083.52,29995.41,
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,599,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5524.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7182.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6202.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6202.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6381.73,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5635.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5524.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5524.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6083.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19025,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5524.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5524.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5524.88,19025,
NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,600,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7812.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10155.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6138.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6138.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6315.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7968.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7812.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7812.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6020.03,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13316.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7812.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7812.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6020.03,13316.25,
NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,601,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5270,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6851,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4589.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4589.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4721.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5375.4,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5270,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5270,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4500.78,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18544.07,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5270,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5270,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4500.78,18544.07,
CELLULITIS WITH MCC,602,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10808.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14051.18,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9114.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9114.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9377.58,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11024.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10808.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10808.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8939.38,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12537.87,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10808.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10808.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8939.38,14051.18,
CELLULITIS WITHOUT MCC,603,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6899.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8968.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5896.46,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5896.46,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6066.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7037.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6899.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6899.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5783.07,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25670.65,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6899.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6899.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5783.07,25670.65,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC",604,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10929.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14208.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6488.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6488.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6675.61,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11148.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10929.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10929.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6363.67,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15706.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10929.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10929.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6363.67,15706.62,
"TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC",605,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7055.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9172.1,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4655.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4655.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4789.38,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7196.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7055.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7055.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4565.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26881.87,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7055.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7055.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4565.58,26881.87,
MINOR SKIN DISORDERS WITH MCC,606,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11446.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14879.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6103.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6103.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6279.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11675.03,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11446.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11446.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5985.99,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16216.04,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11446.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11446.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5985.99,16216.04,
MINOR SKIN DISORDERS WITHOUT MCC,607,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6956.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9043.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4625.74,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4625.74,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4759.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7095.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6956.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6956.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4536.78,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27339.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6956.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6956.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4536.78,27339.64,
ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,614,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15769.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20500.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17394.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17394.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17896.16,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16084.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15769.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15769.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17059.9,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15108.14,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15769.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15769.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15108.14,20500.13,
ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,615,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10702.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13912.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8556.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8556.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8803.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10916.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10702.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10702.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8392.17,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41856.42,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10702.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10702.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8392.17,41856.42,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",616,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26829.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34877.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,21659.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,21659.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22283.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,27365.6,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26829.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26829.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21242.57,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26286.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,26829.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,26829.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21242.57,34877.73,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",617,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14031.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18241.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12523.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12523.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12884.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14312.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14031.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14031.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12282.24,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,67053.27,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14031.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14031.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12282.24,67053.27,
"AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",618,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8694.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11302.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8854.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8854.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9109.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8868.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8694.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8694.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8684.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34626.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8694.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8694.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8684.1,34626.53,
O.R. PROCEDURES FOR OBESITY WITH MCC,619,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18039.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23451.87,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18326.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18326.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18854.72,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18400.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18039.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18039.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17973.67,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20891.69,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18039.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18039.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17973.67,23451.87,
O.R. PROCEDURES FOR OBESITY WITH CC,620,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11682.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15186.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11784.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11784.91,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12124.87,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11915.83,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11682.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11682.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11558.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,51506.96,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11682.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11682.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11558.29,51506.96,
O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,621,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11001.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14302.42,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9480.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9480.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9753.86,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11221.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11001.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11001.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9298.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30023.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11001.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11001.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9298.08,30023.91,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC",622,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25972.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33763.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,22091.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,22091.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22728.8,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,26491.73,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25972.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25972.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21666.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27697.66,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,25972.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,25972.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21666.72,33763.96,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC",623,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13233.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17203.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12068.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12068.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12416.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13498.19,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13233.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13233.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11836.48,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,64499.03,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13233.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13233.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11836.48,64499.03,
"SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC",624,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8389.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10906.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4841.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4841.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4981.65,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8557.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8389.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8389.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4748.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33568.5,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8389.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8389.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4748.86,33568.5,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC",625,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20106.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26138.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12563.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12563.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12926.19,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20508.95,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20106.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20106.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12322.17,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17616.07,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20106.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20106.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12322.17,26138.85,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC",626,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10837.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14088.28,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10620.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10620.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10926.66,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11053.88,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10837.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10837.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10416.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,51248.69,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10837.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10837.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10416.08,51248.69,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC",627,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9177.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11930.74,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7735.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7735.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7958.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9361.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9177.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9177.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7586.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28841.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9177.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9177.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7586.4,28841.19,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC",628,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27197.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35356.61,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16134.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16134.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16599.76,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,27741.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27197.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27197.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15824.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22726.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,27197.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,27197.39,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15824.08,35356.61,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC",629,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15836.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20587.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16134.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16134.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16599.76,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16153.53,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15836.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15836.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15824.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,64921.18,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15836.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15836.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15824.08,64921.18,
"OTHER ENDOCRINE, NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC",630,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10217.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13282.26,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7998.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7998.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8228.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10421.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10217.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10217.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7844.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39966.57,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10217.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10217.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7844.29,39966.57,
DIABETES WITH MCC,637,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10560.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13729.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9014.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9014.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9274.58,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10772.06,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10560.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10560.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8841.2,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25011.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10560.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10560.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8841.2,25011.61,
DIABETES WITH CC,638,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6994.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9092.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5261.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5261.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5412.86,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7134.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6994.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6994.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5159.93,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24860.21,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6994.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6994.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5159.93,24860.21,
DIABETES WITHOUT CC/MCC,639,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5198.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6758.26,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3664.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3664.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3769.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5302.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5198.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5198.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3593.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15603.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5198.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5198.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3593.56,15603.31,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC",640,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9691.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12598.48,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6473.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6473.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6659.82,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9884.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9691.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9691.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6348.62,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,10701.45,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9691.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9691.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6348.62,12598.48,
"MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC",641,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6229.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8097.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4957.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4957.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5100.44,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6353.78,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6229.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6229.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4862.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22537.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6229.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6229.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4862.1,22537.52,
INBORN AND OTHER DISORDERS OF METABOLISM,642,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9613.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12498.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6135.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6135.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6312.37,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9806.25,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9613.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9613.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6017.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13718.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9613.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9613.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6017.41,13718.8,
ENDOCRINE DISORDERS WITH MCC,643,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11830.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15379.92,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11375.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11375.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11703.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12067.32,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11830.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11830.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11156.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24995.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11830.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11830.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11156.39,24995.58,
ENDOCRINE DISORDERS WITH CC,644,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8047.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10461.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6033.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6033.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6208,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8208.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8047.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8047.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5917.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29277.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8047.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8047.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5917.91,29277.58,
ENDOCRINE DISORDERS WITHOUT CC/MCC,645,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6096.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7925.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4639.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4639.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4772.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6218.18,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6096.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6096.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4549.87,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18152.21,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6096.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6096.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4549.87,18152.21,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,650,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30329.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39428.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9720.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9720.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10001.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,30936.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30329.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30329.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9533.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13227.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,30329.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,30329.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9533.72,39428.83,
KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,651,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23590.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30668.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,57382.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,57382.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,59038.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,24062.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23590.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23590.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,56279.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,82717.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23590.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,23590.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23590.82,82717.15,
KIDNEY TRANSPLANT,652,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20646.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26840.32,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,92193.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,92193.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,94852.46,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21059.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20646.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20646.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,90420.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,63164.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20646.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20646.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20646.4,94852.46,
MAJOR BLADDER PROCEDURES WITH MCC,653,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,36271.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,47152.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,31896.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,31896.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32817.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,36996.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,36271.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36271.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31283.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,54951.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,36271.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,36271.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31283.58,54951.8,
MAJOR BLADDER PROCEDURES WITH CC,654,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18915.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24590.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14611.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14611.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15032.83,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19293.74,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18915.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18915.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14330.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,98975.94,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18915.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18915.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14330.37,98975.94,
MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,655,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14831.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19281,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12041.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12041.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12389.23,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15128.17,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14831.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14831.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11810.3,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,50630.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14831.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14831.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11810.3,50630.61,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,656,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21510.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27963.35,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18164.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18164.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18688.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21940.48,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21510.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21510.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17815.27,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,38450.76,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21510.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,21510.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17815.27,38450.76,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,657,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13121.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17058.55,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15870.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15870.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16328.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13384.4,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13121.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13121.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15565.53,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,58874,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13121.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13121.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13121.96,58874,
KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,658,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10762.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13991.32,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11865.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11865.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12207.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10977.8,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10762.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10762.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11637.49,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33450.94,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10762.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10762.55,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10762.55,33450.94,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,659,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17951.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23337.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16777.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16777.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17261.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18310.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17951.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17951.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16454.43,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28125.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17951.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17951.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16454.43,28125.15,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,660,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9890.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12857.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9166.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9166.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9430.45,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10088.06,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9890.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9890.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8989.78,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,45899.74,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9890.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9890.25,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8989.78,45899.74,
KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,661,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7960.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10349.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8131.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8131.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8366.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8120.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7960.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7960.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7975.21,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25136.29,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7960.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7960.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7960.82,25136.29,
MINOR BLADDER PROCEDURES WITH MCC,662,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20596.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26775.4,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,22882.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,22882.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23542.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21008.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20596.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20596.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22442.38,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19199.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20596.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,20596.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19199.55,26775.4,
MINOR BLADDER PROCEDURES WITH CC,663,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10623.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13810.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8832.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8832.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9087.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10836.24,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10623.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10623.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8662.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,54125.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10623.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10623.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8662.5,54125.32,
MINOR BLADDER PROCEDURES WITHOUT CC/MCC,664,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8046.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10460.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6793.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6793.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6989.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8207.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8046.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8046.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6662.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27163.3,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8046.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8046.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6662.81,27163.3,
PROSTATECTOMY WITH MCC,665,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21195.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27554.45,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17364.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17364.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17865.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21619.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21195.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21195.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17030.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20068.78,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21195.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,21195.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17030.45,27554.45,
PROSTATECTOMY WITH CC,666,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12299.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15989.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11306.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11306.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11632.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12545.6,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12299.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12299.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11088.97,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,54510.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12299.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12299.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11088.97,54510.06,
PROSTATECTOMY WITHOUT CC/MCC,667,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7968.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10359.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6642.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6642.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6834.23,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8127.98,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7968.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7968.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6514.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30670.48,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7968.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7968.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6514.88,30670.48,
TRANSURETHRAL PROCEDURES WITH MCC,668,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19437.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25268.79,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16620.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16620.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17100.33,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19826.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19437.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19437.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16301.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17525.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19437.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,19437.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16301.26,25268.79,
TRANSURETHRAL PROCEDURES WITH CC,669,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11114.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14448.28,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7640.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7640.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7860.77,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11336.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11114.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11114.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7493.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,50281.49,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11114.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11114.06,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7493.45,50281.49,
TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,670,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7404.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9625.67,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5147.64,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5147.64,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5296.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7552.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7404.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7404.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5048.65,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28039.65,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7404.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7404.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5048.65,28039.65,
URETHRAL PROCEDURES WITH CC/MCC,671,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12263.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15943.12,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9178.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9178.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9442.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12509.22,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12263.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12263.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9001.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17589.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12263.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12263.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9001.56,17589.35,
URETHRAL PROCEDURES WITHOUT CC/MCC,672,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7241.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9414.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7997.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7997.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8228.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7386.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7241.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7241.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7843.64,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32622.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7241.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7241.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7241.59,32622.68,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,673,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25144.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32688.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17728.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17728.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18239.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25647.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25144.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25144.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17387.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18554.76,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,25144.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,25144.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17387.18,32688.16,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,674,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16611.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21594.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17081.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17081.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17574.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16943.37,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16611.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16611.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16752.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,62235.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16611.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16611.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16611.15,62235.13,
OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,675,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14885.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8726.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8726.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8978.64,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11679.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8559.08,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,42223.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11450.65,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8559.08,42223.35,
RENAL FAILURE WITH MCC,682,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10894.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14163.31,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8843.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8843.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9098.11,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11112.75,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10894.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10894.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8672.97,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30038.16,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10894.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10894.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8672.97,30038.16,
RENAL FAILURE WITH CC,683,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7003.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9104.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6236.17,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6236.17,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6416.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7143.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7003.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7003.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6116.25,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26479.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7003.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7003.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6116.25,26479.32,
RENAL FAILURE WITHOUT CC/MCC,684,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5107.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6640.21,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3866.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3866.24,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3977.76,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5210.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5107.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5107.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3791.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15939.96,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5107.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5107.85,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3791.89,15939.96,
KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,686,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13090.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17018.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6932.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6932.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7132.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13352.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13090.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13090.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6799.61,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,10772.7,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13090.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13090.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6799.61,17018.09,
KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,687,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7940.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10322.95,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5392.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5392.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5548.13,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8099.54,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7940.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7940.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5288.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30241.21,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7940.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7940.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5288.88,30241.21,
KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,688,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6225.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8093.74,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3509.18,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3509.18,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3610.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6350.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6225.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6225.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3441.7,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18520.92,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6225.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6225.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3441.7,18520.92,
KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,689,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8777.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11411.39,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7354.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7354.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7566.88,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8953.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8777.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8777.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7213.3,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15432.32,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8777.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8777.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7213.3,15432.32,
KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,690,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6394.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8312.97,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5210.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5210.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5360.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6522.48,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6394.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6394.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5110.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20432.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6394.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6394.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5110.18,20432.15,
URINARY STONES WITH MCC,693,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10346.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13450.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6380.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6380.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6565.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10553.78,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10346.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10346.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6258.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14171.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10346.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10346.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6258.29,14171.23,
URINARY STONES WITHOUT MCC,694,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6237.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8108.93,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4896.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4896.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5037.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6362.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6237.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6237.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4801.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25485.41,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6237.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6237.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4801.88,25485.41,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,695,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8918.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11593.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6437.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6437.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6623.43,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9096.43,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8918.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8918.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6313.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14197.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8918.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8918.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6313.92,14197.95,
KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,696,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5650.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7345.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3468.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3468.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3568.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5763.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5650.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5650.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3401.77,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20453.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5650.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5650.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3401.77,20453.52,
URETHRAL STRICTURE,697,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10894.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4060.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4060.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4177.58,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8548.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3982.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12343.72,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8380.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3982.37,12343.72,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,698,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11891.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15458.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9233.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9233.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9499.8,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12128.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11891.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11891.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9055.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17676.63,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11891.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11891.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9055.89,17676.63,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,699,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7781.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10116.38,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6567.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6567.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6757.32,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7937.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7781.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7781.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6441.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28543.73,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7781.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7781.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6441.56,28543.73,
OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,700,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5755.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7481.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4646.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4646.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4780.46,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5870.21,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5755.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5755.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4557.07,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18027.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5755.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5755.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4557.07,18027.53,
MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,707,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13885.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18050.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12673.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12673.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13039.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14163.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13885.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13885.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12430.17,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13195.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13885.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13885.3,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12430.17,18050.89,
MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,708,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10620.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13806.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7692.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7692.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7914.33,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10832.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10620.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10620.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7544.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35540.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10620.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10620.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7544.5,35540.28,
PENIS PROCEDURES WITH CC/MCC,709,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15240.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19812.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10070.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10070.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10360.86,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15544.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15240.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15240.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9876.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26445.48,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15240.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15240.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9876.72,26445.48,
PENIS PROCEDURES WITHOUT CC/MCC,710,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9575.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12447.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6423.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6423.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6609.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9766.55,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9575.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9575.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6300.18,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,42962.54,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9575.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9575.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6300.18,42962.54,
TESTES PROCEDURES WITH CC/MCC,711,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14929.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19408.29,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12430.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12430.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12789.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15228.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14929.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14929.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12191.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25674.22,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14929.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,14929.45,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12191.91,25674.22,
TESTES PROCEDURES WITHOUT CC/MCC,712,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8868.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11529.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7229.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7229.26,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7437.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9046.17,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8868.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8868.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7090.24,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36397.04,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8868.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8868.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7090.24,36397.04,
TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,713,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10569.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13740.92,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9000.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9000.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9260.16,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10781.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10569.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10569.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8827.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22115.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10569.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10569.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8827.45,22115.38,
TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,714,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7377.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9591.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5266.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5266.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5418.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7525.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7377.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7377.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5165.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26395.6,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7377.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7377.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5165.16,26395.6,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,715,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15478.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20121.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,16342.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,16342.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16814,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15787.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15478.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15478.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16028.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17067.46,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15478.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15478.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15478.14,20121.58,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,716,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10385.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13500.62,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14790.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14790.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15216.85,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10592.79,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10385.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10385.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14505.79,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39777.76,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10385.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10385.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10385.09,39777.76,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,717,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12924.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16801.4,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10108.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10108.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10400,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13182.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12924.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12924.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9914.03,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23410.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12924.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12924.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9914.03,23410.31,
OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,718,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8787.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11423.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9362.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9362.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9633.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8962.81,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8787.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8787.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9182.88,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31532.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8787.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8787.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8787.07,31532.58,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC",722,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13320.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17316.53,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13045.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13045.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13421.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13586.82,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13320.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13320.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12794.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22603.43,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13320.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13320.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12794.76,22603.43,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC",723,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8388.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10904.67,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5451.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5451.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5608.56,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8555.97,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8388.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8388.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5346.48,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30239.43,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8388.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8388.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5346.48,30239.43,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",724,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6411.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8334.87,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5451.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5451.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5608.56,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6539.67,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6411.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6411.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5346.48,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20526.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6411.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6411.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5346.48,20526.55,
BENIGN PROSTATIC HYPERTROPHY WITH MCC,725,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9209.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11972.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5304.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5304.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5457.49,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9393.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9209.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9209.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5202.47,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13627.96,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9209.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9209.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5202.47,13627.96,
BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,726,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5901.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7672.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3806.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3806.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3916.65,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6019.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5901.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5901.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3733.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22252.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5901.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5901.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3733.63,22252.53,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,727,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15176.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6179.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6179.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6357.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11907.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6060.61,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13743.74,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,11674.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6060.61,15176.73,
INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,728,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6350.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8255.62,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5554.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5554.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5714.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6477.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6350.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6350.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5447.28,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25592.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6350.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6350.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5447.28,25592.28,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,729,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7672.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9973.89,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5770.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5770.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5937.46,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7825.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7672.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7672.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5660.01,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14636.12,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7672.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7672.22,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5660.01,14636.12,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,730,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5192.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6750.68,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3613.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3613.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3718.21,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5296.69,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5192.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5192.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3544.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19197.77,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5192.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5192.83,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3544.46,19197.77,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC",734,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15258.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19835.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12712.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12712.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13079.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15563.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15258.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15258.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12468.14,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11681.11,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15258.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,15258.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11681.11,19835.76,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC",735,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9334.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12134.77,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8414.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8414.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8657.28,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9521.13,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9334.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9334.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8252.74,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,38922.78,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9334.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9334.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8252.74,38922.78,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,736,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26371.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34283.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19015.5,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19015.5,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19564.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,26899.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26371.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26371.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18649.84,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,22660.43,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,26371.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,26371.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18649.84,34283.33,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,737,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13962.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18151.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10654.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10654.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10961.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14241.73,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13962.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13962.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10449.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,75971.74,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13962.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13962.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10449.46,75971.74,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,738,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10011.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13015,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8020.12,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8020.12,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8251.47,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10211.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10011.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10011.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7865.9,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36042.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10011.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10011.54,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7865.9,36042.58,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,739,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24614.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31999.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17106.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17106.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17599.53,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25107.18,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24614.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24614.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16777.13,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25004.49,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,24614.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,24614.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16777.13,31999.34,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,740,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12750.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16576.27,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11981.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11981.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12327.43,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13006,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12750.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12750.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11751.39,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,69507.77,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12750.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12750.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11751.39,69507.77,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,741,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9588.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12464.44,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6501.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6501.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6689.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9779.79,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9588.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9588.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6376.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32104.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9588.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9588.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6376.76,32104.35,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,742,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12717.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16533.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7838.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7838.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8064.7,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12972.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12717.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12717.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7687.85,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23385.37,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12717.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12717.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7687.85,23385.37,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,743,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8697.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11306.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5919.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5919.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6089.9,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8871.52,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8697.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8697.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5805.33,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32099.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8697.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8697.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5805.33,32099.01,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC",744,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13369.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17380.62,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7960.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7960.72,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8190.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13637.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13369.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13369.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7807.64,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20850.73,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13369.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13369.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7807.64,20850.73,
"D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC",745,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7879.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10243.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5107.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5107.6,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5254.93,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8037.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7879.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7879.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5009.38,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33812.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7879.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7879.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5009.38,33812.52,
"VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC",746,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12031.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15641.28,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7620.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7620.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7840.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12272.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12031.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12031.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7473.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20498.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12031.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12031.75,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7473.81,20498.05,
"VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC",747,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6915.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8989.98,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5644.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5644.85,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5807.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7053.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6915.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6915.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5536.3,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27847.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6915.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6915.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5536.3,27847.28,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,748,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10272.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13354.77,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6120.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6120.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6297.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10478.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10272.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10272.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6003.01,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17430.82,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10272.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10272.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6003.01,17430.82,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,749,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17486.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22732.7,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13262.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13262.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13645.11,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17836.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17486.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17486.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13007.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25243.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17486.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17486.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13007.5,25243.17,
OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,750,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9981.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12976.21,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7178.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7178.53,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7385.61,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10181.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9981.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9981.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7040.49,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,44996.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9981.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,9981.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7040.49,44996.67,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC",754,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13175.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17128.51,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8572.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8572.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8820.02,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13439.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13175.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13175.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8407.87,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25417.72,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13175.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,13175.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8407.87,25417.72,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC",755,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8196.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10655.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7739.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7739.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7963.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8360.16,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8196.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8196.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7590.98,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30937.66,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8196.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8196.24,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7590.98,30937.66,
"MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",756,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7580.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9854.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4771.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4771.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4909.55,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7731.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7580.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7580.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4680.13,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19256.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7580.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4588.36,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7580.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4588.36,19256.55,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC",757,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10835.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14085.73,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6659.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6659.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6852.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11051.88,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10835.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10835.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6531.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17755,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10835.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6403.81,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10835.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6403.81,17755,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC",758,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7598.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9878.61,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5381.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5381.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5537.15,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7750.91,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7598.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7598.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5278.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24441.63,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7598.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5174.9,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7598.93,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5174.9,24441.63,
"INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC",759,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5352.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6958.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4095.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4095.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4213.28,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5459.41,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5352.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5352.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4016.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17019.37,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5352.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3937.65,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5352.36,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3937.65,17019.37,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,760,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7617.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9902.23,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4913.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4913.38,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5055.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7769.44,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7617.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7617.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4818.9,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11050.56,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7617.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4724.41,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7617.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4724.41,11050.56,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,761,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5089.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6615.77,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3826.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3826.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3937.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5190.83,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5089.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5089.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3753.27,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17217.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5089.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3679.67,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5089.05,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3679.67,17217.08,
VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,768,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9061.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11779.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5455.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5455.98,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5613.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9242.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9061.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9061.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5351.06,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,10076.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9061.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5246.13,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9061.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5246.13,11779.83,
POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,769,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11174.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14526.68,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8676.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8676.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8927.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11397.86,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11174.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11174.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8509.99,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20426.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11174.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8343.12,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11174.37,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8343.12,20426.8,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",770,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8243.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4324.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4324.07,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4448.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6468.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4240.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29591.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4157.76,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6341.4,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4157.76,29591.08,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,776,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5809.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7552.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4328.74,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4328.74,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4453.61,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5925.78,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5809.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5809.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4245.5,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15421.63,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5809.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4162.25,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5809.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4162.25,15421.63,
ABORTION WITHOUT D&C,779,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7576.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9849.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3583.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3583.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3687.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7728.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7576.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7576.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3515.01,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12416.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7576.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3446.08,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7576.88,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3446.08,12416.75,
CESAREAN SECTION WITH STERILIZATION WITH MCC,783,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12652.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16448.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12905.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12652.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12652.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18143.3,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12652.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12652.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12652.41,18143.3,
CESAREAN SECTION WITH STERILIZATION WITH CC,784,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7803.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10144.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7959.29,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7803.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7803.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,34371.82,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7803.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7803.23,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7803.23,34371.82,
CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,785,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6779.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8813.77,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6915.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6779.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6779.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,18595.73,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6779.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6779.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6779.82,18595.73,
CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,786,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12507.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16260.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12757.94,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12507.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12507.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16246.33,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12507.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12507.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12507.78,16260.11,
CESAREAN SECTION WITHOUT STERILIZATION WITH CC,787,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7978.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10371.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4763.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4763.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4900.62,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8137.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7978.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7978.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4671.62,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28766.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7978.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4580.02,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7978.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4580.02,28766.38,
CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,788,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6706.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8718.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5175,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5175,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5324.28,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6840.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6706.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6706.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5075.49,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18975.12,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6706.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4975.97,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6706.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4975.97,18975.12,
"NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY",789,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12961.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16849.46,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13349.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13349.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13734.37,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13220.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12961.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12961.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13092.59,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15539.19,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12961.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12835.86,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12961.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12835.86,16849.46,
"EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE",790,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40074.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,52097.42,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4761.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4761.88,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4899.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,40876.44,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40074.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40074.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4670.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32521.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,40074.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4578.74,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,40074.94,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4578.74,52097.42,
PREMATURITY WITH MAJOR PROBLEMS,791,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27736.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36058.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,2505.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,2505.41,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,2577.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,28291.71,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27736.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27736.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2457.23,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,107247.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,27736.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2409.05,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,27736.97,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2409.05,107247.83,
PREMATURITY WITHOUT MAJOR PROBLEMS,792,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17196.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22355.81,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,1889.4,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,1889.4,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,1943.91,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17540.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17196.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17196.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,1853.07,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,73244.73,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17196.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,1816.73,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,17196.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,1816.73,73244.73,
FULL TERM NEONATE WITH MAJOR PROBLEMS,793,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28460.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36998.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11667.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11667.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12004.02,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,29029.98,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28460.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28460.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11443.09,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,44195.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,28460.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11218.71,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,28460.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11218.71,44195.13,
NEONATE WITH OTHER SIGNIFICANT PROBLEMS,794,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10824.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14071.41,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,28531.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,28531.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29354.97,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11040.64,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10824.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10824.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27983.27,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,75237.89,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10824.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27434.56,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10824.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10824.16,75237.89,
NORMAL NEWBORN,795,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,2469.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3210.44,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,1456.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,1456.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,1498.96,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,2518.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,2469.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2469.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,1428.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26630.72,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,2469.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,1400.89,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,2469.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,1400.89,26630.72,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,796,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10360.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13468.57,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7027.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7027.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7230.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10567.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10360.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10360.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6892.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,3605.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10360.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6757.41,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10360.44,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3605.15,13468.57,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,797,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7620.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9906.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7027.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7027.7,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7230.42,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7772.74,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7620.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7620.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6892.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23387.16,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7620.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6757.41,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7620.33,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6757.41,23387.16,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,798,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6577.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8550.7,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6709.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6577.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6577.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,16527.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6577.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6577.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6577.46,16527.75,
SPLENIC PROCEDURES WITH MCC,799,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33294.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,43282.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19128.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19128.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19680.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,33960.27,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33294.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33294.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18760.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16527.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,33294.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18392.59,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,33294.38,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16527.75,43282.69,
SPLENIC PROCEDURES WITH CC,800,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19435.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25266.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14270.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14270.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14681.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19824.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19435.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19435.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13995.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,92759.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19435.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13721.45,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,19435.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13721.45,92759.55,
SPLENIC PROCEDURES WITHOUT CC/MCC,801,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12768.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16599.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9378.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9378.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9648.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13023.88,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12768.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12768.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9197.93,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,47353.2,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12768.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9017.58,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12768.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9017.58,47353.2,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,802,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23411.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30435.35,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18456.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18456.22,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18988.62,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23880.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23411.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23411.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18101.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31990.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23411.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17746.37,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,23411.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17746.37,31990.35,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,803,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13212.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17176.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8901.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8901.75,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9158.54,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13477.02,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13212.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13212.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8730.57,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,67899.34,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13212.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8559.38,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13212.76,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8559.38,67899.34,
OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,804,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9011.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11714.91,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7326.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7326.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7537.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9191.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9011.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9011.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7185.15,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36573.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9011.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7044.26,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9011.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7044.26,36573.38,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,805,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7700.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10010.14,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7854.11,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7700.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7700.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,22475.18,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7700.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7700.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7700.11,22475.18,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,806,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6004.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7805.4,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6124.23,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6004.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6004.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,17911.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6004.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6004.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6004.15,17911.75,
VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,807,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5404.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7026.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5512.99,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5404.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5404.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12429.21,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5404.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5404.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5404.89,12429.21,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,808,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15365.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19974.88,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19148.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19148.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19700.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15672.6,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15365.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15365.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18780.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11246.5,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15365.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18411.85,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15365.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11246.5,19974.88,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,809,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8972.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11664.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9059.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9059.93,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9321.27,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9152.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8972.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8972.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8885.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,38135.49,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8972.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8711.47,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8972.56,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8711.47,38135.49,
MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,810,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7676.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9978.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4613.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4613.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4746.12,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7829.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7676.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7676.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4524.35,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21654.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7676.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4435.63,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7676.11,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4435.63,21654.05,
RED BLOOD CELL DISORDERS WITH MCC,811,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10264.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13343.81,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10000.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10000.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10289.45,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10469.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10264.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10264.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9808.64,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16721.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10264.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9616.31,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10264.47,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9616.31,16721.91,
RED BLOOD CELL DISORDERS WITHOUT MCC,812,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7002.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9103.8,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5665.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5665.54,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5828.97,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7142.98,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7002.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7002.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5556.59,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24764.02,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7002.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5447.64,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7002.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5447.64,24764.02,
COAGULATION DISORDERS,813,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11278.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14662.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8147.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8147.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8382.62,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11504.37,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11278.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11278.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7990.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15995.18,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11278.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7834.23,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11278.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7834.23,15995.18,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,814,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14963.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19452.15,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7505.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7505.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7722.07,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15262.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14963.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14963.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7361.23,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27877.56,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14963.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7216.88,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14963.19,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7216.88,27877.56,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,815,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7609.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9892.1,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5886.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5886.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6056.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7761.5,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7609.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7609.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5773.25,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33470.53,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7609.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5660.05,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7609.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5660.05,33470.53,
RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,816,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5767.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7497.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3869.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3869.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3981.2,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5882.78,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5767.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5767.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3795.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18365.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5767.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3720.74,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5767.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3720.74,18365.95,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,817,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19429.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25258.65,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,19818.32,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19429.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19429.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12984.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19429.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,19429.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12984.95,25258.65,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,818,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10442.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13575.65,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10651.67,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10442.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10442.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,55748,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10442.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,10442.81,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10442.81,55748,
OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,819,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7045.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9158.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7185.97,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7045.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7045.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,28322.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7045.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,7045.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7045.07,28322.86,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,820,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40377.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,52490.32,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,31466.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,31466.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32374.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,41184.71,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40377.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40377.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30861.38,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15825.96,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,40377.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30256.24,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,40377.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15825.96,52490.32,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,821,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15637.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20328.98,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13288.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13288.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13671.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15950.43,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15637.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15637.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13033.02,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,94717.09,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15637.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12777.47,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15637.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12777.47,94717.09,
LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,822,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9195.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11954.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7525.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7525.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7742.67,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9379.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9195.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9195.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7380.86,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,38516.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9195.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7236.14,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9195.66,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7236.14,38516.67,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,823,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30358.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39465.93,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,24840.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,24840.55,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25557.11,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,30965.58,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,30358.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30358.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24362.87,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21463.46,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,30358.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23885.15,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,30358.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21463.46,39465.93,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,824,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15642.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20335.72,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13398.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13398.01,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13784.5,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15955.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15642.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15642.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13140.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,77061.84,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15642.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12882.71,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15642.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12882.71,77061.84,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,825,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9536.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12397.83,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8780.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8780.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9033.57,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9727.53,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9536.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9536.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8611.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,40794.82,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9536.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8442.59,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9536.79,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8442.59,40794.82,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,826,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31174.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40526.55,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,26308.16,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,26308.16,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27067.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,31797.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31174.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31174.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25802.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23451.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,31174.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25296.32,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,31174.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23451.28,40526.55,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,827,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16189.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21046.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11712.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11712.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12050.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,16513.38,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16189.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16189.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11487.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,91587.52,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,16189.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11262.34,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,16189.59,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11262.34,91587.52,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,828,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11800.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15340.27,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8441.25,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8441.25,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8684.75,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12036.21,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11800.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11800.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8278.93,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,43366.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11800.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8116.59,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11800.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8116.59,43366.88,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,829,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21615.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28099.94,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15378.18,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15378.18,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15821.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22047.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21615.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21615.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15082.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30976.85,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21615.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14786.72,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,21615.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14786.72,30976.85,
MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,830,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11416.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14841.18,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6376.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6376.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6560.94,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11644.62,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11416.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11416.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6254.36,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,56369.64,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11416.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6131.72,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11416.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6131.72,56369.64,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,831,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8135.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10575.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8297.98,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8135.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8135.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,26192.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8135.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,8135.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8135.27,26192.55,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,832,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5945.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7729.54,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6064.72,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5945.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5945.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,21281.78,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5945.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,5945.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5945.8,21281.78,
OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,833,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4480.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5824.95,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,4570.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4480.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4480.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,12477.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,4480.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,4480.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4480.73,12477.31,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,834,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,37473.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,48715.72,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,55014.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,55014.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,56601.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,38223.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,37473.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37473.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,53956.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,8977.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,37473.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,52898.36,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,37473.63,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8977.25,56601.25,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,835,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15659.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20357.65,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15789.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15789.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,16244.77,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15972.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15659.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15659.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15485.68,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,98500.36,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15659.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15182.02,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15659.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15182.02,98500.36,
ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,836,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10318.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13413.78,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6392.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6392.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6576.73,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10524.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10318.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10318.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6269.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37353.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10318.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6146.48,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10318.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6146.48,37353.55,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,837,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32577.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,42350.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,31216.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,31216.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32116.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,33228.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,32577.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32577.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30615.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27943.47,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,32577.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,30015.59,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,32577.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27943.47,42350.22,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,838,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14143.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18386.46,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9862.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9862.81,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10147.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14426.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14143.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14143.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9673.15,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,95867.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14143.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9483.47,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14143.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9483.47,95867.75,
CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,839,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9612.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12496.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6703.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6703.35,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6896.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9804.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9612.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9612.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6574.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39615.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9612.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6445.53,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9612.67,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6445.53,39615.67,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,840,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21429.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27858.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,27765.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,27765.09,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,28566.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21858.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21429.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21429.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27231.17,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24486.16,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,21429.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26697.21,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,21429.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21429.86,28566.01,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,841,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11366.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14776.26,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9485.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9485.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9759.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11593.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11366.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11366.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9303.32,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,55341.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11366.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9120.89,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11366.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9120.89,55341.88,
LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,842,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8077.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10500.84,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7593.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7593.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7812.7,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8239.12,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8077.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8077.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7447.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28406.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8077.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7301.59,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8077.57,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7301.59,28406.58,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,843,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13228.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17196.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8463.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8463.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8707.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13492.89,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13228.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13228.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8300.53,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19659.1,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13228.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8137.77,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13228.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8137.77,19659.1,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,844,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8666.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11266.36,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5722.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5722.27,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5887.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8839.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8666.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8666.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5612.23,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34508.97,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8666.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5502.18,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8666.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5502.18,34508.97,
OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,845,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6770.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8801.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4818.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4818.61,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4957.61,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6906.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6770.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6770.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4725.95,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,20316.37,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6770.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4633.28,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6770.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4633.28,20316.37,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,846,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17011.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22115.54,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14644.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14644.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15066.47,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17352.19,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17011.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17011.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14362.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15060.05,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17011.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14080.82,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,17011.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14080.82,22115.54,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,847,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9025.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11733.46,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8227.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8227.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8464.33,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9206.25,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9025.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9025.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8068.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,42909.11,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9025.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7910.59,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9025.74,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7910.59,42909.11,
CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,848,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6584.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8559.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4112.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4112.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4231.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6716.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6584.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6584.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4033.42,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21696.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6584.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3954.33,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6584.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3954.33,21696.8,
RADIOTHERAPY,849,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18616.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24201.4,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5767.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5767.65,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5934.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,18988.79,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18616.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18616.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5656.74,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16549.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18616.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5545.82,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,18616.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5545.82,24201.4,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,853,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33584.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,43659.58,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,37378.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,37378.96,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38457.21,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,34255.98,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,33584.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33584.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36660.17,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,41660.49,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,33584.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35941.32,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,33584.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33584.29,43659.58,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,854,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14380.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18694.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15458.94,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15458.94,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15904.87,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14667.75,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14380.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14380.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15161.67,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,87296.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14380.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14864.37,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14380.15,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14380.15,87296.61,
INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,855,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12198.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15857.96,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9752.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9752.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10034.02,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12442.4,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12198.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12198.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9565.14,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36614.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12198.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9377.59,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12198.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9377.59,36614.35,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,856,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29881.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38846.25,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,26775.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,26775.34,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27547.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,30479.36,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29881.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29881.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26260.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27211.39,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,29881.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25745.53,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,29881.73,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25745.53,38846.25,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,857,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15012.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19516.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11914.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11914.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12258.08,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15312.74,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15012.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15012.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11685.28,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,78599.01,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15012.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11456.15,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15012.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11456.15,78599.01,
POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,858,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9484.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12330.37,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10438.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10438.77,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10739.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9674.6,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9484.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9484.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10238.04,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37565.51,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9484.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10037.28,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9484.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9484.9,37565.51,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,862,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13107.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17040,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10482.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10482.15,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10784.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13369.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13107.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13107.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10280.58,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,25196.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13107.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10079,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13107.69,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10079,25196.86,
POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,863,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7682.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9987.38,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5750.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5750.97,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5916.86,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7836.25,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7682.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7682.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5640.38,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32579.93,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7682.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5529.78,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7682.6,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5529.78,32579.93,
FEVER AND INFLAMMATORY CONDITIONS,864,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6886.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8952.87,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5390.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5390.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5546.07,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7024.56,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6886.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6886.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5286.91,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,17917.09,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6886.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5183.25,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6886.82,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5183.25,17917.09,
VIRAL ILLNESS WITH MCC,865,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11796.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15336.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5236.4,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5236.4,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5387.46,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12032.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11796.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11796.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5135.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15108.14,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11796.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5035.01,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11796.98,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5035.01,15336.07,
VIRAL ILLNESS WITHOUT MCC,866,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7113.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9247.11,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4798.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4798.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4937.01,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7255.42,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7113.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7113.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4706.32,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29795.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7113.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4614.03,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7113.16,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4614.03,29795.91,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,867,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14731,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19150.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11816.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11816.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12157.82,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15025.62,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14731,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14731,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11589.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16025.46,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14731,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11362.45,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14731,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11362.45,19150.3,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,868,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8201.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10661.86,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5177.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5177.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5327.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8365.46,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8201.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8201.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5078.11,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,37643.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8201.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4978.53,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8201.43,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4978.53,37643.88,
OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,869,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5640.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7333.25,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5177.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5177.67,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5327.03,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5753.78,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5640.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5640.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5078.11,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18804.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5640.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4978.53,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5640.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4978.53,18804.13,
SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,870,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,46332.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,60231.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,39898.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,39898.39,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,41049.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,47258.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,46332.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,46332.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,39131.15,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13195.13,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,46332.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38363.84,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,46332.12,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13195.13,60231.76,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,7,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,104929.33,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,66651.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,66651.04,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,68573.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,82329.17,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,65369.34,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,120959.51,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,64087.55,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,80714.87,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,64087.55,120959.51,
SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,872,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7840.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10193.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6643.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6643.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6834.91,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7997.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7840.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7840.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6515.53,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,34861.65,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7840.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6387.77,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7840.84,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6387.77,34861.65,
O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,876,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25362,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32970.6,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,13073.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,13073.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13450.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25869.24,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25362,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25362,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12822.25,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18310.74,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,25362,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12570.83,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,25362,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12570.83,32970.6,
ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,880,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7352.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9558.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4129.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4129.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4248.99,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7499.54,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7352.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7352.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4050.44,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,56932.5,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7352.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3971.02,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7352.49,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3971.02,56932.5,
DEPRESSIVE NEUROSES,881,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7040.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9152.68,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3562.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3562.57,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3665.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7181.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7040.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7040.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3494.06,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16141.23,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7040.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3425.55,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7040.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3425.55,16141.23,
NEUROSES EXCEPT DEPRESSIVE,882,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7253.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9429.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3670.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3670.02,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3775.89,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7398.33,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7253.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7253.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3599.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15238.17,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7253.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3528.87,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7253.26,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3528.87,15238.17,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,883,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13324.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17321.6,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5262.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5262.43,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5414.24,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13590.8,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13324.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13324.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5161.24,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15558.78,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13324.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5060.03,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13324.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5060.03,17321.6,
ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,884,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12555.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16322.51,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7480.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7480.2,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7695.97,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12806.9,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12555.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12555.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7336.35,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,28757.47,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12555.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7192.5,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12555.78,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7192.5,28757.47,
PSYCHOSES,885,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10023.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13030.16,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4820.62,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4820.62,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4959.67,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10223.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10023.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10023.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4727.92,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27964.84,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10023.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4635.21,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10023.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4635.21,27964.84,
BEHAVIORAL AND DEVELOPMENTAL DISORDERS,886,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12068.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15688.49,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3815.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3815.51,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3925.58,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12309.43,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12068.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12068.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3742.14,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23075.45,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12068.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3668.76,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12068.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3668.76,23075.45,
OTHER MENTAL DISORDER DIAGNOSES,887,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9564.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12433.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3971.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3971.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4086.25,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9755.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9564.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9564.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3895.31,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24313.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9564.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3818.93,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9564.03,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3818.93,24313.38,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA",894,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4887.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6353.56,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3854.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3854.89,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3966.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,4985.1,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4887.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4887.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3780.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23093.26,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,4887.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3706.63,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,4887.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3706.63,23093.26,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY",895,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11595.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15073.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,2949.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,2949.9,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3034.99,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11827.18,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11595.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11595.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2893.17,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,10184.9,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11595.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2836.44,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11595.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,2836.44,15073.85,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC",896,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12693.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16501.25,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9329.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9329.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9598.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12947.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12693.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12693.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9150.15,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27763.56,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12693.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8970.73,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12693.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8970.73,27763.56,
"ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC",897,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6710.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8723.55,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6844.63,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6710.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6710.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,31270.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6710.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable for inpatient setting,6710.42,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6710.42,31270.75,
WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,901,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29229.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,37998.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,20503.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,20503.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,21095.26,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,29813.87,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29229.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29229.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20109.52,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15163.36,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,29229.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19715.2,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,29229.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15163.36,37998.06,
WOUND DEBRIDEMENTS FOR INJURIES WITH CC,902,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13384.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17400.01,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9205.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9205.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9470.96,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13652.31,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13384.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13384.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9028.4,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,78347.86,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13384.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8851.37,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13384.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8851.37,78347.86,
WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,903,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9213.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11977.12,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6679.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6679.99,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6872.68,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9397.43,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9213.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9213.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6551.53,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,35299.82,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9213.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6423.07,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9213.17,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6423.07,35299.82,
SKIN GRAFTS FOR INJURIES WITH CC/MCC,904,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22279.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28963.3,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17576.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17576.59,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18083.61,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22725.05,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22279.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22279.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17238.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21652.27,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22279.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16900.57,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,22279.46,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16900.57,28963.3,
SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,905,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11432.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14862.26,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9233.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9233.45,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9499.8,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11661.16,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11432.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11432.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9055.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,63266.44,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11432.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8878.32,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11432.51,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8878.32,63266.44,
HAND PROCEDURES FOR INJURIES,906,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13364.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17373.88,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7023.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7023.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7225.62,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13631.81,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13364.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13364.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6887.98,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27784.94,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13364.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6752.91,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13364.52,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6752.91,27784.94,
OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,907,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25284.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32869.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,29035.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,29035.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29873.39,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,25789.86,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25284.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25284.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28477.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31844.29,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,25284.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27919.06,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,25284.18,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25284.18,32869.43,
OTHER O.R. PROCEDURES FOR INJURIES WITH CC,908,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14158.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18406.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11690.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11690.14,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12027.36,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14442.17,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14158.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14158.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11465.34,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,68855.85,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14158.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11240.53,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14158.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11240.53,68855.85,
OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,909,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9957.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12945.01,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8183.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8183.63,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8419.7,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10156.85,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9957.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9957.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8026.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36630.38,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9957.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7868.88,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9957.7,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7868.88,36630.38,
TRAUMATIC INJURY WITH MCC,913,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10854,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14110.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7570.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7570.3,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7788.67,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11071.08,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10854,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10854,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7424.72,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24308.04,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10854,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7279.13,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10854,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7279.13,24308.04,
TRAUMATIC INJURY WITHOUT MCC,914,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7048.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9162.82,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4609.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4609.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4742,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7189.29,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7048.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7048.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4520.42,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26969.15,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7048.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4431.78,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7048.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4431.78,26969.15,
ALLERGIC REACTIONS WITH MCC,915,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12666.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16466.68,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10678.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10678.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10986.4,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12920.01,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12666.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12666.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10473.02,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,15836.65,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12666.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10267.66,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12666.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10267.66,16466.68,
ALLERGIC REACTIONS WITHOUT MCC,916,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5434.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7064.32,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4129.19,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4129.19,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4248.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5542.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5434.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5434.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4049.79,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,32419.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5434.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3970.38,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5434.09,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3970.38,32419.62,
POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,917,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11511.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14965.09,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8422.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8422.56,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8665.52,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11741.84,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11511.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11511.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8260.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,11830.73,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11511.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8098.62,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11511.61,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8098.62,14965.09,
POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,918,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6744.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8768.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,4391.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,4391.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4518.16,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6879.7,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6744.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6744.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4307.03,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27118.77,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6744.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4222.58,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6744.8,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4222.58,27118.77,
COMPLICATIONS OF TREATMENT WITH MCC,919,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12995.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16894.12,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7941.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7941.37,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8170.45,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13255.39,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12995.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12995.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7788.66,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,14564.87,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12995.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7635.93,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12995.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7635.93,16894.12,
COMPLICATIONS OF TREATMENT WITH CC,920,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7866.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10225.97,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7329.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7329.36,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7540.79,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8023.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7866.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7866.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7188.42,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,31947.6,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7866.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7047.47,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7866.13,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7047.47,31947.6,
COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,921,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5687.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7393.13,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5054.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5054.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5200.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5800.76,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5687.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5687.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4957.67,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,18200.3,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5687.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4860.46,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5687.02,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4860.46,18200.3,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC",922,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12477.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16221.34,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8943.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8943.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9201.8,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12727.51,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12477.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12477.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8771.81,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12965.35,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12477.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8599.81,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12477.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8599.81,16221.34,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC",923,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7720.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10037.12,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5250.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5250.42,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5401.88,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7875.28,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7720.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7720.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5149.45,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,27711.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7720.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5048.48,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7720.86,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5048.48,27711.91,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,927,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,172110.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,223743.18,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,90497.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,90497.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,93108.37,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,175552.34,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,172110.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,172110.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,88757.57,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16800.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,172110.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,87017.17,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,172110.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16800.28,223743.18,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,928,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,46038.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,59850.69,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14927.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14927.69,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15358.3,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,46959.77,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,46038.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,46038.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14640.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,338110.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,46038.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14353.55,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,46038.99,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14353.55,338110.95,
FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,929,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22015.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28620.15,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7138.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7138.49,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7344.41,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22455.81,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22015.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22015.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7001.22,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,110279.44,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22015.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6863.93,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,22015.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6863.93,110279.44,
EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,933,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20825.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27073.03,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,24458.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,24458.8,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,25164.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,21241.92,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20825.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20825.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23988.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,52345.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20825.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23518.08,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,20825.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20825.41,52345.91,
FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,934,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14732.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19152,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6417.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6417.03,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6602.14,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15026.96,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14732.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14732.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6293.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,54023.8,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14732.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6170.22,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14732.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6170.22,54023.8,
NON-EXTENSIVE BURNS,935,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14398.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18718.64,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5769.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5769.66,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5936.09,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,14686.93,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14398.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14398.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5658.71,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33415.31,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,14398.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5547.75,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,14398.95,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5547.75,33415.31,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,939,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22014.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28618.47,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,17728.76,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,17728.76,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18240.17,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,22454.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22014.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22014.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17387.84,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,36053.27,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,22014.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17046.89,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,22014.21,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17046.89,36053.27,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,940,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15212.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19776.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11710.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11710.83,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12048.65,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,15517.15,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15212.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15212.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11485.63,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,55165.55,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,15212.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11260.42,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,15212.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11260.42,55165.55,
O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,941,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13198.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17158.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8857.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8857.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9113.22,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,13462.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,13198.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13198.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8687.37,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,39245.18,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,13198.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8517.03,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,13198.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8517.03,39245.18,
REHABILITATION WITH CC/MCC,945,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10951.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14236.65,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,23717.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,23717.32,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,24401.48,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11170.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10951.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10951.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23261.24,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,33618.37,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10951.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22805.12,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10951.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10951.27,33618.37,
REHABILITATION WITHOUT CC/MCC,946,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7729.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10048.08,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5398.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5398.58,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5554.31,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7883.88,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7729.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7729.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5294.77,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26810.62,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7729.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5190.95,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7729.29,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5190.95,26810.62,
SIGNS AND SYMPTOMS WITH MCC,947,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9278.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12062.28,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,10195.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,10195.84,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10489.95,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,9464.25,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9278.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9278.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9999.77,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,19995.75,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,9278.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9803.69,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,9278.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9278.68,19995.75,
SIGNS AND SYMPTOMS WITHOUT MCC,948,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6356.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8263.22,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5490.68,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5490.68,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5649.07,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6483.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6356.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6356.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5385.1,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21652.27,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6356.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5279.5,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6356.32,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5279.5,21652.27,
AFTERCARE WITH CC/MCC,949,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8119.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10554.79,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14695.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14695.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15119.35,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8281.45,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8119.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8119.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14412.84,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,13850.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8119.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14130.23,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8119.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8119.07,15119.35,
AFTERCARE WITHOUT CC/MCC,950,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5303.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6893.99,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5132.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5132.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5280.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5409.13,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,5303.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5303.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5033.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,21231.9,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,5303.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4934.9,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,5303.07,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4934.9,21231.9,
OTHER FACTORS INFLUENCING HEALTH STATUS,951,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4987.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6484.26,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,3405.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,3405.06,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,3503.29,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,5087.65,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,4987.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,4987.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3339.59,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,12637.61,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,4987.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3274.1,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,4987.89,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,3274.1,12637.61,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,955,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40659.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,52857.06,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,39681.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,39681.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40826.15,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,41472.47,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,40659.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,40659.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38918.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,10138.59,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,40659.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,38155.28,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,40659.28,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10138.59,52857.06,
"LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA",956,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26313.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,34207.43,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,37283.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,37283.52,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,38359.02,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,26839.68,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,26313.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26313.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,36566.56,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,119981.63,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,26313.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35849.55,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,26313.41,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26313.41,119981.63,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,957,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,48067.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,62487.93,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,56531.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,56531.95,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,58162.69,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,49028.99,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,48067.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,48067.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,55444.84,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,67760.41,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,48067.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,54357.65,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,48067.64,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,48067.64,67760.41,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,958,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27393.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,35612.07,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,23292.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,23292.86,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23964.77,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,27941.78,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27393.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27393.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22844.94,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,131995.83,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,27393.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22396.98,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,27393.9,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22396.98,131995.83,
OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,959,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17585.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22860.85,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,14347.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,14347.05,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,14760.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17936.98,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17585.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17585.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14071.16,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,74284.95,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17585.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13795.25,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,17585.27,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13795.25,74284.95,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,963,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18894.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24563.08,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,21692.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,21692.44,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,22318.18,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19272.57,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,18894.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18894.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,21275.29,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,45753.68,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,18894.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20858.12,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,18894.68,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18894.68,45753.68,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,964,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10896.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14164.98,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,12149.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,12149.31,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12499.78,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,11114.06,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10896.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10896.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11915.68,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,49396.24,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10896.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11682.03,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10896.14,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10896.14,49396.24,
OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,965,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7360.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9569.2,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6033.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6033.28,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6207.32,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,7508.14,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,7360.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7360.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5917.26,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,26085.67,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,7360.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5801.23,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,7360.92,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5801.23,26085.67,
HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,969,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45733.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,59453.59,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,28719.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,28719.47,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,29547.92,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,46648.2,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,45733.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,45733.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,28167.2,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16207.14,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,45733.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,27614.88,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,45733.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,16207.14,59453.59,
HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,970,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19188.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,24945.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,19303.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,19303.82,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19860.66,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,19572.25,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19188.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,19188.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18932.61,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,129094.25,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,19188.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18561.37,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,19188.48,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18561.37,129094.25,
HIV WITH MAJOR RELATED CONDITION WITH MCC,974,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20076.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26099.24,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,18821.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,18821.29,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,19364.22,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,20477.87,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,20076.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,20076.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18459.36,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,55010.58,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,20076.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18097.4,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,20076.34,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,18097.4,55010.58,
HIV WITH MAJOR RELATED CONDITION WITH CC,975,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10003.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13004.03,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,7950.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,7950.71,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8180.06,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10203.16,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10003.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10003.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7797.82,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,51173.88,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10003.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7644.92,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10003.1,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7644.92,51173.88,
HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,976,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6643.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8636.71,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,5849.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,5849.08,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6017.8,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,6776.49,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6643.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6643.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5736.6,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,24503.97,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,6643.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5624.11,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,6643.62,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,5624.11,24503.97,
HIV WITH OR WITHOUT OTHER RELATED CONDITION,977,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10345.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,13449.19,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,8098.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,8098.21,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8331.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,10552.44,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,10345.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10345.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7942.48,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,16436.91,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,10345.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7786.74,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,10345.53,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,7786.74,16436.91,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,981,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31905.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,41476.76,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,33859.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,33859.1,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,34835.81,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,32543.3,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,31905.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,31905.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,33208,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,23153.82,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,31905.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,32556.84,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,31905.2,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23153.82,41476.76,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,982,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17284.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,22469.66,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,15341.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,15341.48,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,15784.02,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,17630.04,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,17284.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,17284.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15046.46,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,81586.08,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,17284.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14751.42,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,17284.35,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,14751.42,81586.08,
EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,983,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11766.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15296.45,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,9306.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,9306.87,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,9575.33,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12001.83,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11766.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11766.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,9127.89,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,44676.06,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,11766.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8948.91,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,11766.5,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8948.91,44676.06,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,987,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23060.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,29979.25,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,26579.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,26579.13,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,27345.84,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,23522.18,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,23060.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23060.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,26068.01,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,29749.6,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,23060.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,25556.86,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,23060.96,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,23060.96,29979.25,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,988,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12167.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,15817.5,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,11612.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,11612.73,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,11947.71,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,12410.66,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,12167.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,12167.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11389.41,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,59107.34,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,12167.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11166.08,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,12167.31,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,11166.08,59107.34,
NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,989,MS-DRG,,,,,inpatient,,,,,,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8167.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,10618.02,130,MS-DRG,,other,130% CMS MS-DRG for inpatient setting,6501.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,6501.79,104,,,other,Pays at 104% GA Medicaid DRG rates for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,6689.34,107,,,other,Pays at 107% GA Medicaid DRG rates for inpatient setting,8331.06,102,MS-DRG,,other,102% CMS MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,,,,,other,Not separately reimbursable by MS-DRG for inpatient setting,8167.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,8167.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6376.76,102,,,other,Pays at 102% GA Medicaid DRG rates for inpatient setting,30216.28,100,,,other,Pays at 100% UHC DRG rates for inpatient setting,8167.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6251.72,100,,,other,Pays at 100% GA Medicaid DRG rates for inpatient setting,8167.71,100,MS-DRG,,other,100% CMS MS-DRG for inpatient setting,6251.72,30216.28,